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BRS - Year 2 > 🍔Gastro🍔 - Gastrointestinal Cancers > Flashcards

🍔Gastro🍔 - Gastrointestinal Cancers Flashcards

1
Q

What is cancer?

A

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

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2
Q

What is primary (in the context of cancer)?

A

Arising directly from the cells in an organ

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3
Q

What is secondary (in the context of cancer)?

A

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

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4
Q

What are the types of cancers that arise from epithelial cells?

A

Squamous cells - squamous cell carcinoma (SCC)
Glandular epithelium - adenocarcinoma

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5
Q

What are the types of cancers that arise from neuroendocrine cells?

A

Enteroendocrine cells - neuroendocrine tumours (NETs)
Interstitial cells of Cajal - Gastrointestinal Stromal tumours (GISTs)

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6
Q

What are the types of cancers that arise from connective tissue?

A

Smooth muscle - leiomyoma/leiomyosarcoma
Adipose tissue - liposarcoma

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7
Q

Where can GI NETs arise in the GI tract?

A

Anywhere along the tract

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8
Q

What is the most common GI cancer (at least in the West)?

A

Colorectal cancer

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9
Q

Outline the risks and epidemiology of colorectal cancer

A

Third most common cancer death in men and women
Lifetime risk: 1 in 10 men, 1 in 14 women
Generally affect patients > 50 years

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10
Q

What are the 3 forms of colorectal cancer?

A

Sporadic - absence of Fmx, older, isolate lesion
Familial
Hereditary syndrome - Fmx, younger, Lynch syndrome etc…

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11
Q

What is the histopathology of colorectal cancer?

A

Adenocarcinoma

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12
Q

What is the pathogenesis of colorectal cancer?

A
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13
Q

What are the risk factors for colorectal cancer?

A

Pmx - colorectal cancer (remission), adenoma, UC, radiotherapy
Fmx - 1st degree relative < 55 yrs
Relatives with identified genetic predisposition
Diet/Environmental:
?carcinogenic foods - debated
Smoking
Obesity
Socioeconomic status

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14
Q

Where are CRCs usually located?

A

⅔ in descending colon and rectum
½ in sigmoid colon and rectum (i.e. within reach of flexible sigmoidoscopy)

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15
Q

What are the presentations of caecal and right sided CRCs?

A

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

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16
Q

What are the presentations for Left sided & sigmoid carcinoma?

A

PR bleeding, mucus
Thin stool (late)

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17
Q

What are the presentations for rectal carcinoma?

A

PR bleeding, mucus
Tenesmus
Anal, perineal, sacral pain (late)

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18
Q

What is a common symptom for CRC among all locations?

A

Bowel obstruction
Late stage disease

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19
Q

What symptoms of local invasion can you get with CRCs, indicative of late stage disease?

A

Bladder symptoms
Female genital tract symptoms

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20
Q

What are the possible symptoms of metastasis can you get with CRC?

A

Liver (hepatic pain, jaundice)
Lung (cough)
Regional lymph nodes
Peritoneum - Sister Marie Joseph nodule

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21
Q

What are the signs of primary CRC?

A

Abdominal mass
DRE: most <12cm dentate and reached by examining finger
Rigid sigmoidoscopy
Abdominal tenderness and distension – large bowel obstruction

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22
Q

What are the classic signs of metastasis and complications for CRC?

A

Hepatomegaly (mets)
Monophonic wheeze
Bone pain

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23
Q

What are the investigations that can be done in a case of suspected CRC?

A

Faecal occult blood - FIT (Faecal Immunochemical Test) - detects minute amounts of blood in faeces
Blood tests - FBC: anaemia, haematinics - low ferritin
Tumour markers - CEA useful for monitoring, but not a diagnostic tool

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24
Q

What is the first line invasive investigation for CRC?

A

Colonoscopy
Can visualize lesions < 5mm
Small polyps can be removed - reduced cancer incidence
Usually performed under sedation

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25
Q

What imaging technique can be used as an investigation for CRC?

A

CT colonoscopy/colonography
Can visualize lesions > 5mm
No need for sedation
Less invasive, better tolerated
If lesions identified patient needs colonoscopy for diagnosis

26
Q

What other imaging tests can be performed in a case of CRC (particularly late presenting)?

A

MRI pelvis – Rectal Cancer
Depth of invasion, mesorectal lymph node involvement
Help choose between preoperative chemoradiotherapy or straight to surgery

CT Chest/Abdo/Pelvis (CT CAP)
Staging prior to treatment

27
Q

How is colon cancer primarily managed?

A

Surgery
Some cases can use a stent, radiotherapy or chemotherapy

28
Q

What is the surgical treatment for an obstructing colon carcinoma of the right and transverse colon?

A

Resection and primary anastomosis

29
Q

What is the surgical treatment for obstructing colon carcinoma of the left sided colon?

A

Hartmann’s procedure
Proximal end colostomy (LIF)
+/- Reversal in 6 months
Primary anastomosis
Palliative stent

30
Q

What is primary anastomosis?

A

Surgical procedure that joins together body channels, such as the bowel or blood vessels

31
Q

Outline a right hemicolectomy

A
32
Q

Outline an extended right hemicolectomy

A
33
Q

Outline the resection in a left sided cancer?

A
34
Q

Outline the resection in rectal cancer?

A
35
Q

What are the most significant types of liver cancer?

A

Hepatocellular carcinoma (HCC)
CRC - secondary to CRC, a metastasis
Gallbladder cancer
Cholangiocarcinoma (ChCA)

36
Q

Outline HCC

A

70-90% have underlying cirrhosis
Aflatoxin
Poor prognosis - Median survival without Rx 4-6m, 5yr survival <5%

37
Q

What is the treatment for HCC?

A

Systemic chemotherapy ineffective
Optimal Rx surgical excision with curative intent - 5yr survival >30%
5-15% suitable for surgery

38
Q

Outline gallbladder cancer

A

Aetiology unknown
Median survival without Rx 5-8m
5yr survival <5%

39
Q

What is the treatment for gallbladder cancer?

A

Optimal Rx surgical excision with curative intent - 5yr survival: stage II 64%; stage III 44%; stage IV 8%
<15% suitable for surgery

40
Q

Outline cholangiocarcinoma

A

Aetiology - PSC (chronic inflammation of bile ducts) & UC, liver fluke (clonorchis sinesis), choledochal cyst
Median survival (depends on site) without Rx <6 m
5yr survival <5%
Systemic chemotherapy ineffective
GEMCIS - median overall survival 11.7 months*

41
Q

What is the treatment for cholangiocarcinoma?

A

Optimal Rx surgical excision with curative intent - 5yr survival 20-40%
20-30% suitable for surgery

42
Q

Outline Secondary liver metastases (CRC)

A

15-20% synchronous, 25% metachronous
median survival without Rx <1yr
5yr survival 0%
Systemic chemotherapy improving

43
Q

What is the treatment for secondary liver metastases from CRC?

A

Optimal Rx surgical excision with curative intent - 5yr survival rates of 25-50%
25% suitable for surgery

44
Q

Outline pancreatic cancer

A

Relatively common & highly lethal
Commonest form of panc CA is pancreatic ductal adenocarcinoma (PDA)
80-85% have late presentation (median survival <6 months)
15-20% have resectable disease
(Median survival 11-20 months
5-year survival 20–25%
Virtually all pts dead within 7 years of surgery)
Incidence & mortality roughly equivalent

45
Q

What are the risk factors for pancreatic cancer?

A

Chronic pancreatitis → 18-fold ↑er risk
Type II diabetes mellitus → 1.8x
Occupation (insecticides, aluminium, nickel & acrylamide)
Cigarette smoking → causes 25-30% PDAs
7-10% have a family history (1st degree relatives)

46
Q

How doe pancreatic cancers arise?

A

Pancreatic Intraepithelial Neoplasias (PanIN)
PDAs evolve through non-invasive neoplastic precursor lesions

47
Q

What is the clinical presentation of carcinoma of the head of the pancreas?

A

Jaundice >90% due to either invasion or compression of CBD - often painless
Weight loss
Pain 70% at the time of diagnosis - radiates to back in 25%, indicating posterior capsule invasion and irresectability
5% atypical attack of acute pancreatitis
GI bleeding

At least two-thirds of PDAs arise in the head

48
Q

What is the clinical presentation of carcinoma of the body and tail of the pancreas?

A

Develop insidiously and are asymptomatic in early stages
Often more advanced at diagnosis
Marked weight loss with back pain in 60% of patients
Jaundice uncommon
Most unresectable at time of diagnosis

49
Q

What are the investigations for pancreatic cancer?

A

Tumour marker CA19-9
Ultrasonography
Dual-phase CT - accurately predicts resectability in 80–90% of cases
MRI
MRCP
ERCP

50
Q

Outline tumour marker CA19-9 as a marker for pancreatic cancer

A

Falsely elevated in pancreatitis, hepatic dysfunction & obstructive jaundice
Concentrations > 200 U/ml confer 90% sensitivity
Concentrations in the thousands associated with high specificity

51
Q

What investigations can be used to detect occult metastases of pancreatic cancer?

A

Laparoscopy & laparoscopic ultrasound- detect radiologically occult metastatic lesions of liver & peritoneal cavity
PET mainly used for demonstrating occult metastases

52
Q

What are NETs?

A

Neuroendocrine tumours
Arise from the gastroenteropancreatic (GEP) tract
Sporadic tumours in 75%
Associated with a genetic syndrome in 25 such as MEN1

53
Q

What is MEN1?

A

Multiple Endocrine NeoplasiaType 1
Parathyroidtumours
Pancreatic tumours
Pituitarytumours
NETs

54
Q

How do NETs present?

A

Most NETs are asymptomatic & incidental findings
Secretion of hormones & their metabolites in 40%
Can result in a variety of debilitating effects:
Carcinoid syndrome: vasodilation, bronchoconstriction, increased intestinal motility, endocardial fibrosis

55
Q

Outline the pancreatic NETs

A
56
Q

Outline the duodenal NETs

A

Gastrinoma - Zollinger-Ellison syndrome - G cells

57
Q

Outline NETs of the gastrointestinal tract more broadly

A

VIP - vasoactive intestinal peptide

58
Q

How are NETs diagnosed?

A

Biochemical assessment
Imaging

59
Q

What biochemical assessments can confirm the presence of NETs?

A

Chromogranin A is a secretory product of NETs
Other gut hormones measure in fasting state
Other screening - calcium, PTH, prolacting, GH etc…
24 hr urinary 5-HIAA (serotonin metabolite)

60
Q

What imaging methods can be used to confirm the presence of NETs?

A

Cross-sectional imaging (CT and/or MRI)
Bowel imaging (endoscopy, barium follow through, capsule endoscopy)
Endoscopic ultrasound
Somatostatin receptor scintigraphy

61
Q

What is the treatment for NETs?

A

Curative resection

BRS - Year 2 (61 decks)

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