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GASTROENTEROLOGY 2 > GASTROINTESTINAL CANCERS > Flashcards

GASTROINTESTINAL CANCERS Flashcards

1
Q

Which cancers arise from epithelial cells?

A

Squamous cell carcinoma - squamous epithelium

Adenocarcinoma - glandular metaplastic columnar epithelium

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2
Q

Which cancers arise from neuroendocrine cells?

A 
Neuroendocrine tumours (NETs) - enteroendocrine cells
Gastrointestinal stromal tumours (GISTs) - interstitial cells of Cajal
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3
Q

Which cancers arise from connective tissue?

A

Leiomyoma/leiomyosarcomas - smooth muscle

Liposarcomas - adipose tissue

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4
Q

How does alcohol increase risk of oesophageal cancer?

A

Via the acetaldehyde pathway (metabolism of alcohol which produces acetaldehyde - a carcinogen)

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5
Q

What part of the oesophagus does SSC affect?

A

upper 2/3

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6
Q

What part of the oesophagus does adenocarcinoma affect?

A

lower 1/3

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7
Q

What is oesophageal adenocarcinoma related to?

A

Acid reflux

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8
Q

Describe the steps from acid reflux to oesophageal adenocarcinoma

A

Oesophagitis - inflammation from GORD
Barrett’s - metaplasia 5% of GORD population
Adenocarcinoma - neoplasia

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9
Q

What are the stages of progression of Barrett’s oesophagus to adenocarcinoma which can be seen on biopsy?

A

Dysplasia (low grade)
Dysplasia (high grade)
Adenocarcinoma

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10
Q

How often do the different stages of dysplasia for Barrett’s need to be surveilled?

A

No dysplasia - every 2/3 years
LGD - every 6 months
HGD - intervention (likely invasive cancer)

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11
Q

What population does oesophageal cancer affect?

A

elderly with adenocarcinoma 10:1 male:female

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12
Q

How does oesophageal cancers present?

A

Late presentation with dysphagia and weight loss

Palliation is difficult and must rely on stents

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13
Q

What is the prognosis for oesophageal cancer patients?

A

High morbidity and a complex surgery
65% of patients palliative

5-year survival < 20% even with surgery

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14
Q

How are oesophageal cancers diagnosed?

A

Endoscopy then biopsy to confirm

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15
Q

What procedures can you undertake to stage oesophageal cancers?

A

CT scan
Laparoscopy - check metastases

Maybe endoscopic ultrasound if cancer is submucosal/not in visible in lumen

Maybe PET scan to pick up on metastases that aren’t seen by other imaging

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16
Q

How are oesophageal cancers treated?

A

Curative:
Squamous cell carcinoma- radiotherapy usually
Adenocarcinomas - neo-adjuvant chemo then surgery

Palliative (65%):

  • Chemo
  • DXT
  • Stent
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17
Q

What is a surgical procedure for oesophageal adenocarcinomas?

A

2 stage Ivor Lewis oesophagectomy:

  • Remove upper part of stomach
  • Open chest and resect malignant oesophagus
  • Rejoin stomach and oesophagus
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18
Q

What is the most common GI cancer in western societies?

A

Colorectal cancer

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19
Q

What age group does colorectal cancer tend to affect?

A

> 50 years

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20
Q

What is the lifetime risk for men and women

A

1/10 for men
1/14 for women

3rd most common cancer death

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21
Q

What are the 3 forms of colorectal cancer?

A

Sporadic - acquired, older population, isolated lesion

Familial - genetics (relative is usually close), more risk if < 50 years

Hereditary syndrome - genetics, younger age of onset, specific gene defects.

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22
Q

What are some examples of hereditary syndrome colorectal cancer?

A

Familial adenomatous polyposis (FAP)

Hereditary nonpolyposis colorectal cancer (Lynch syndrome)

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23
Q

What is the histopathology of colorectal cancer?

A

Adenocarcinoma

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24
Q

What are the risk factors for colorectal cancer?

A

Past history of colorectal cancer, adenoma, ulcerative colitis, radiotherapy

Family history
Diet/Environmental - smoking, obesity etc.

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25
Q

How does a left sided and sigmoid colorectal carcinoma present?

A 
PR bleeding and mucus
Thin stool (late)
Bowel obstruction (late)
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26
Q

How does a rectal colorectal carcinoma present?

A

PR bleeding and mucus
Tenesmus (wanting to poop but nothing comes out)
Anal/perineal/sacral pain (late)
Bowel obstruction (late)

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27
Q

How does a caecal and right sided carcinoma present?

A

Iron deficiency anaemia - tumour more likely to bleed
Change of bowel habit (diarrhoea)

Distal ileum obstruction (late)
Palpable mass (late)
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28
Q

How will a late local invasion of colorectal cancer present?

A

Bladder symptoms

Female genital tract symptoms

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29
Q

How will a late metastasis of colorectal cancer present?

A 
Liver (hepatic pain, jaundice, hepatomegaly)
Lung (cough, monophonic wheeze)
Regional lymph nodes
Peritoneum (sister Mary Joseph nodule)
Bone pain
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30
Q

What are some signs that a colorectal cancer is primary?

A 
Abdominal mass (late)
< 12 cm from pectinate/dentate line
Abdominal tenderness and distention - large bowel obstruction
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31
Q

List the tests that can be done to investigate colorectal cancer

A

Faecal occult blood (blood invisible in poo)tests:

  • Guaiac test
  • Faecal immunochemical test (FIT)

Blood tests:
- FBC (anaemia, haematinics, ferritin)
- Tumour markers (not diagnosis tool) e.g. CEA for
monitoring

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32
Q

Describe the guaicac test

A

Test for colorectal cancer based on pseudoperoxidase activity of haematin

Must avoid red meat, melons, horse-radish, vitamin C and NSAIDs for 3 days before test

33
Q

What imaging can be done to investigate colorectal cancer?

A

Colonoscopy
CT colonoscopy/colonography
Pelvic MRI for rectal cancer
CT chest/abdo/pelvis

34
Q

Why is colonoscopy done for colorectal cancer patients?

A

Can see lesions < 5mm
Small polyps can be removed to reduce cancer incidence

Performed under sedation

35
Q

Why is CT colonoscopy/colonography done for colorectal cancer patients?

A

Can see lesions > 5mm
No need for sedation and less invasive/better tolerated than normal colonoscopy

However if lesions are identified patient will still nee colonoscopy for diagnosis

36
Q

Why is pelvic MRI done for rectal cancer patients?

A

Check depth of invasion and mesorectal lymph node involvement.
No bowel prep or sedation
Helps to choose between preoperative chemo/radiotherapy or straight to surgery

37
Q

Why is CT chest/abdo/pelvis done for rectal cancer patients?

A

Staging prior to treatment

38
Q

How is colorectal cancer managed?

A

Primarily surgery

Stent/radiotherapy/chemotherapy to give time to plan surgery

39
Q

How would an obstructing colon carcinoma in the right and transverse colon be treated?

A

Resection and primary anastomosis

40
Q

How would a left sided obstructing colon carcinoma be treated?

A

Hartmann’s procedure with/out reversal in 6 months

Primary anastomosis with intraoperative bowel lavage (occasionally done)
- might first do defunctioning ileostomy to allow colon to
heal after resection

Palliative stent

41
Q

What is Hartmann’s procedure?

A

Resect away tumour and surrounding colon then join proximal bowel to abdominal skin forming proximal end colostomy

42
Q

List the surgical procedures for resection of a right sided cancer and the parts resected

A

Right hemicolectomy - caecum and ascending colon

Extended right hemicolectomy - portion of transverse colon too

43
Q

Name the surgical procedure for resection of a left sided cancer and the parts resected

A

Left hemicolectomy - descending colon

44
Q

If a patient has rectal cancer what is resected?

A

Part of rectum and part of sigmoid colon

45
Q

What is the most common form of pancreatic cancer?

A

Pancreatic ductal adenocarcinoma (PDA)

46
Q

Why should pancreatic cancer be taken seriously?

A

80-85% have late presentation and 5 year survival is 0.4-5%

Only 15-20% have a resectable disease and virtually all patients are dead with 7 years of surgery

47
Q

What are the risk factors for pancreatic cancer?

A 
Chronic pancreatitis (inflammation, healing cycle)
T2DM
Cholelithiasis
Previous gastric surgery
Pernicious anaemia
Diet
Occupation (insecticides...)
Smoking
Family history
48
Q

What are some inherited syndromes associated with increased pancreatic cancer risk?

A 
Hereditary pancreatitis
Familial atypical multiple mole melanoma
Familial breast-ovarian cancer syndrome
Peutz-Jeghers syndrome
HNPCC (lynch syndrome)
FAP
49
Q

How does pancreatic ductal adenocarcinoma (PDA) evolve?

A

PDAs evolve through non-invasive neoplastic precursor lesions called pancreatic intraepithelial neoplasias (PanIN 1/2/3)

These are similar to colorectal polyps and are microscopic

50
Q

What is the PanIN progression model?

A

PanIN 1
PanIN 2
PanIN 3 (step before pancreatic cancer)

51
Q

How would a carcinoma of the head of the pancreas present?

A

Jaundice (invasion or compression of common bile duct)
Weight loss (malabsorption, diabetes)
Pain (sign of locally invasive)

Acute atypical attack pancreatitis (rare)
Vomiting (advanced - duodenal obstruction)
GI bleeding (duodenal invasion/varices secondary to portal/splenic vein occlusion)
52
Q

What does pain radiating to the back in a patient with pancreatic cancer signify?

A

Basically inoperable since it is now extraperitoneal due to posterior capsule invasion

53
Q

How would a carcinoma of the body and tail of the pancreas present?

A

Develops insidiously and asymptomatic in early stages
When diagnosed much more advanced than pancreatic head lesions

Marked weight loss
Back pain
Vomiting (late stage invasion of DJ flexure)
Most unresectable at time of diagnosis

54
Q

What are the investigations for pancreatic cancer?

A 
Tumour marker CA19-9
Ultrasonography
Dual-phase CT
MRI
MRCP
ERCP
EUS
Laparoscopy + laparoscopic ultrasound
PET
55
Q

What does a tumour marker CA19-9 test show?

A

Falsely elevated in pancreatitis, hepatic dysfunction and obstructive jaundice. Concentrations > 200 U/ml = 90% sensitivity

56
Q

What is the purpose of ultrasonography in pancreatic cancer?

A

Identifies:

  • Pancreatic tumours
  • Dilated bile ducts
  • Liver metastases
57
Q

What is the purpose of dual-phase CT in pancreatic cancer?

A

Predicts resectability, looks at:

  • Contiguous organ invasion
  • Vascular invasion
  • Different metastases
58
Q

What is the purpose of MRI in pancreatic cancer?

A

Detects and predicts resectability - similar to CT

59
Q

What is the purpose of MRCP in pancreatic cancer?

A

Provides ductal images without complications of ERCP

60
Q

What is the purpose of ERCP in pancreatic cancer?

A

Confirms typical ‘double duct’ sign
Aspiration/brushing of bile duct system
Therapeutic modality
Allows you to take biopsies to confirm diagnosis

61
Q

What is the purpose of EUS in pancreatic cancer?

A

Detection of small tumours
Assessing vascular invasion
Fine needle aspirations to look at cells

62
Q

What is the purpose of laparoscopy + laparoscopic ultrasound in pancreatic cancer?

A

Detect radiologically occult metastatic lesions of liver and peritoneal cavity

63
Q

What is the purpose of PET in pancreatic cancer?

A

Mainly for demonstrating occult metastases

64
Q

If a tumour is present at the head of the pancreas what is the surgical procedure?

A

Whipple’s resection - head of pancreas, gall bladder, duodenum, distal bile duct

65
Q

If a tumour is present at the tail of the pancreas what is the surgical procedure?

A

Distal pancreatectomy - tail of pancreas, splenic artery and spleen

66
Q

What are 4 cancers that can affect the liver?

A

Hepatocellular cancer (HCC) (primary liver cancer)
Colorectal cancer liver metastases
Cholangiocarcinoma
Gall bladder cancer

67
Q

Name two potential causes of hepatocellular carcinoma

A

Cirrhosis (70-90%)

Aflatoxin

68
Q

What is the median survival for hepatocellular carcinoma without treatment?

A

4-6 months

69
Q

List the treatments for hepatocellular carcinoma

A

Liver transplant
Transcatheter arterial chemoembolisation (TACE)
Radiofrequency ablation (RFA)
Surgical excision (optimal curative)

70
Q

Why are only 5-15% of hepatocellular carcinoma patients suitable for surgery?

A

Most patients have cirrhosis which limits the amount of liver you can take away as they still need some functioning organ

71
Q

What are the causes for gallbladder cancer?

A

Aetiology unknown but associated with…

Gall stones:

  • porcelain GB (chronic inflammation - calcification)
  • chronic typhoid infection
72
Q

What is the median survival for gallbladder cancer without treatment?

A

5-8 months

73
Q

List the treatments for gallbladder cancer

A

Surgical excision
5 year survival: stage II 64%, stage III 44%, stage IV 8%

Systemic chemotherapy ineffective

74
Q

What are some potential causes for cholangiocarcinoma?

A

Primary sclerosing cholangitis (PSC)
Ulcerative collitis
Liver fluke (worms)
Coledochal cyst

75
Q

What is the median survival for cholangiocarcinoma without treatment?

A

< 6 months

76
Q

List the treatments for cholangiocarcinoma

A

Surgical excision
5 year survival rate 20-40%

Systemic chemotherapy ineffective

77
Q

What is cholangiocarcinoma and where is it usually found?

A

Cancer of bile duct an cells most commonly found at bifurcation of common hepatic duct

78
Q

What is the survival rate of secondary liver metastases e.g. colorectal cancer without treatment?

A

< 1 year

79
Q

List the treatments for secondary liver metastases e.g. colorectal cancer

A

Surgical excision

5 year survival rate 20-50%

GASTROENTEROLOGY 2 (7 decks)

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