Gastrointestinal Cancers Flashcards
1
Q
What is the definition of cancer?
A
a disease characterised by the uncontrolled division of abnormal cells in the body
2
Q
What type of cancer tends to arise from squamous epithelial cells?
A
squamous cell carcinoma
3
Q
What type of cancer tends to arise from glandular epithelial cells?
A
adenocarcinoma
4
Q
What type of cancer tends to arise from enteroendocrine cells?
A
neuroendocrine tumours (NETs)
5
Q
What type of cancer tends to arise from interstitial cells of Cajal cells?
A
Gastrointestinal Stromal Tumours (GISTs)
6
Q
What type of cancer tends to arise from smooth muscle cells?
A
Leiomyoma/leiomyosarcomas
7
Q
What type of cancer tends to arise from adipose tissue cells?
A
Liposarcomas
8
Q
What population is most affected by colorectal cancer?
A
> 50 years old men
9
Q
What is the most common GI cancer in the west?
A
Colorectal cancer
10
Q
What are the different forms of colorectal cancer?
A
- sporadic
- familial
- hereditary syndrome
11
Q
What is the sporadic form of colorectal cancer?
A
- Absence of family history
- Older population
- Isolated lesion
12
Q
What is the familial form of colorectal cancer?
A
Family history, higher risk if:
- index case is young (<50years)
- the relative is close (1st degree)
13
Q
What is the hereditary syndrome form of colorectal cancer?
A
- Family history
- Younger age of onset
- Specific gene defects
e. g. - Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
14
Q
How do people with Familial adenomatous polyposis present?
A
- young polyps
- removals of lots of the large colon at a young age
15
Q
What is thought to prevent the progression of polyps to colorectal cancers?
A
aspirin
16
Q
What are the risk factors of developing Colorectal cancers?
A
PMHx - colorectal cancers - adenoma, ulcerative colitis, radiotherpy FHx - first degree relative - genetic predisposition Lifestyle - smoking - obesity - socioeconomic status - carcinogenic foods
17
Q
Where does colorectal cancer occur?
A
- 2/3 - descending colon, rectum
- 1/2 - sigmoid colon and rectum (seen on sigmoidoscopy)
18
Q
How does caecal and right sided cancer present?
A
- iron deficiency anaemia
- diarrhoea
- distal ileum obstruction (late)
- palpable mass (late)
19
Q
How does sigmoid and left sided cancer present?
A
- PR bleeding
- mucus
- thin stools (late)
20
Q
How does rectal cancer present?
A
- PR bleeding
- mucus
- tenesmus (urge to poo but being unable to)
- anal, perineal and sacral pain
- bowel obstruction (late)
21
Q
What are the late signs of local invasion of a carcinoma?
A
- bladder symptoms
- female genital tract symptoms
22
Q
What are the late signs of metastasis of a carcinoma?
A
- liver: hepatic pain, jaundice
- lung: cough
- regional lymph nodes
- peritoneum: sister mary joseph nodule
23
Q
What are the signs of primary colorectal cancer?
A
- abdominal mass
- digital rectal examination: most < 12cm from dentate line and reached by finger
- rigid sigmoidoscopy
- abdominal tenderness and distension (large bowel obstruction)
24
Q
What are the signs of metastasis and complications of colorectal cancer?
A
- hepatomegaly
- monophonic wheeze
- bone pain
25
How do you diagnose colorectal cancer?
- FIT (faecal immunochemical test) for occult blood
- FBC: anaemia, haematinitcs, low ferritin
- tumour markers: CEA (NOT a diagnostic tool)
26
How do you investigate colorectal cancer?
- colonscopy
- CT colonoscopy/colonography
- MRI pelvis
27
Why is a colonscopy used to investigate colorectal cancer?
- can visualize lesions <5mm
- small polyps can be removed
- reduced cancer incidence
- performed under sedation
28
Why is a CT colonoscopy/colonography used to investigate colorectal cancer?
- can visualize lesions >5mm
- no need for sedation
- less invasive, better tolerated
- colonoscopy is still needed for diagnosis if lesions are identified
- useful for elderly patients
29
Why is a MRI pelvis used to investigate colorectal cancer?
- depth of invasion
- mesorectal lymph node involvement
- no bowel prep or sedation required
- help choose between preop chemoradiotherapy or straight to surgery
30
What scans are used to stage a colorectal cancer prior to treatment?
CT chest/abdomin/pelvis
31
How do you manage an obstructing colon carcinoma in the right and transverse colon?
- resection
- primary anastomosis
32
How do you manage an obstructing colon carcinoma in the left sided colon?
* Hartmann's procedure (emergency operation)
* Primary anastomosis
* Palliative stent
33
What arteries supply the right and transverse colon?
- Iliocolic
- Right colic
- Middle colic
34
What arteries supply the left sided colon?
- branches of inferior mesenteric artery:
- Left colic
- sigmoid arteries
35
What happens in a Right Hemicolectomy?
- right side of the large bowel
- removing the ascending colon, caecum
- connecting the terminal ileum, to the transverse colon
36
What happens in a Extended Right Hemicolectomy?
- remove 2/3 or the large bowel (caecum, ascending colon and part of the transverse colon)
- connect terminal ilium to the remainder of the transverse colon
37
What happens in a Left Hemicolectomy?
- remove the descending colon
- connect transverse colon to the sigmoid colon via anastomosis
38
How do you resect with rectal cancer?
- remove the rectum and part of the sigmoid colon
- connect the remaining colon (sigmoid) to the anus
39
What is normally done instead of a resection with rectal cancer?
iliostomy
40
What is the most common form of pancreatic cancer?
pancreatic ductal adenocarcimona
41
When does pancreatic cancer tend to present?
- late (80-85%)
- only 15-20% have resectable disease
42
When does pancreatic cancer tend to occur?
between 60-80 years of age
43
What are the risk factors of pancreatic cancer?
- chronic pancreatitis (18 fold risk)
- T2DM
- cholelithiasis
- previous gastric surgery
- pernicious anaemia
- diet (high in fat, protein, coffee and etOH)
- occupation (chemical and metal exposure)
- smoking
- family history (hereditary pancreatitis)
44
What are pancreatic intraepithelial neoplasias?
- microscopic (<5mm)
- not visible by pancreatic imaging
- evolve through non-invasive neoplastic precursor lesions
45
What happens in the development of pancreatic ductal adenocarcinomas?
they acquire clonally selected genetic and epigenetic alterations along the way
46
How does a carcinoma at the head of the pancreas present?
(2/3)
- Jaundice
- Weight loss
- Pain
- acute pancreatitis
- GI bleeding
- vomiting
47
What causes jaundice with a carcinoma at the head of the pancreas?
- invasion or compression of the common bile duct
- painless
- Courvoisier's sign (palpable gallbladder)
48
What causes weight loss with a carcinoma at the head of the pancreas?
- anorexia
- malabsorption (due to exocrine insufficiency)
- diabetes
49
What causes pain with a carcinoma at the head of the pancreas?
- epigastrium
- radiates to the back
50
What does back pain with a carcinoma at the head of the pancreas indicate?
- posterior capsule invasion
- irresectability
51
What does vomiting with a carcinoma at the head of the pancreas indicate?
duodenal obstruction
52
What does GI bleeding with a carcinoma at the head of the pancreas indicate?
- duodenal invasion
- varices (due to portal or splenic vein occlusions)
53
How does a carcinoma at the body and tail of the pancreas present?
- asymptomatic at the early stages
- weight loss
- back pain
- vomiting
- unresectable at time of diagnosis
- jaundice unlikely
54
What does vomiting with a carcinoma at the body and tail of the pancreas indicate?
(late) - invasion of the DJ flexure
55
What investigations can be done with pancreatic cancer?
- ***Tumour marker: CA19-9***
- ***Abdominal ultrasound***
- Dual-phase CT
- MRI
- MRCP
- ERCP
- EUS
- laparoscopy and laparascopic US
- PET
56
What does the Tumour marker: CA19-9 indicate?
- falsely elevated in: pancreatitis, hepatic dysfunction and obstructive jaundice
- conc. >200U/ml = 90% sensitivity
- conc. > 1000 = high sensitivity
57
What can an ultrasonography detect?
- identify pancreatic tumours
- dilated bile ducts
- liver metastases
58
What can a dual-phase CT detect?
- accurately predict resectability in 80-90% of cases
- contiguous organ invasion
- vascular invasion (coeliac axis and SMA)
- distant metastases
59
What can an MRI detect?
detects and predicts resectability with accuracies similar to a CT
60
What can an MRCP detect?
provides ductal images without ERCP complications
61
What can an ERCP detect?
- confirms the typical double duct sign
- aspiration/brushing of the bile-duct system
- therapeutic modality - biliary stenting to relieve jaundice
62
What can an EUS detect?
- highly sensitive in the detection of small tumours
- assesses vascular invasion
- FNA
63
What can a laparoscopy and laparoscopic US detect?
radiologically occult metastatic lesions of liver and peritoneal cavity
64
What can a PET detect?
demonstrates occult metastases
65
When do you do a whipple resection?
when the carcinoma is at the head of the pancreas
66
What is a whipple resection?
- remove: distal bile duct, gall bladder, distal stomach, all of the duodenum until the jejunum starts
- bile duct, stomach and remaining pancreas attach to the small intestine
67
What is a TOP resection?
remove distal part of pancreas (tail and body), spleen
68
What are the 4 different types of liver cancer?
- Hepatocellular cancer
- Cholangiocarcinoma
- Gall Bladder cancers
- Colorectal cancer liver metastases
69
Where does hepatocellular cancer occur?
in the hepatocytes of the liver itself
70
What can cause hepatocellular carcinoma?
- cirrhosis (from alcohol or Hep B)
- aflatoxin
71
Where does Cholangiocarcinoma occur?
- bile ducts, the bifurcation of the common hepatic duct
72
How do you treat hepatocellular cancer?
```
(chemo is ineffective)
Optimal is surgical excision with curative intent
- liver transplant
- transarterial haemoembolisation
- radiofrequency ablation
```
73
What is associated with gallbladder cancer?
- gallstones
- porcelain gall bladder
- chronic typhoid infections
74
How do you treat gallbladder cancer?
* surgical excision with curative intent
* chemo is ineffective
75
What is the 5 year survival rate of gallbladder cancer?
stage 2: 64%
stage 3: 44%
stage 4: 8%
76
What is thought to cause Cholangiocarcinoma?
- choledochal cyst
- ulcerative colitis and primary scloerosing cholangitis
- liver flukes
77
How do you treat Cholangiocarcinoma?
surgical excision with curative intent
78
How do you treat secondary liver metastases?
* surgical excision with curative intent
* chemo improving
79
How do you surgically resect a hepatocellular cancer?
remove the affected part of the liver (as little as possible)
80
How do you surgically resect a gallbladder cancer?
remove the gallbladder, all the lymphnodes, liver tissue surrounding
81
How do you surgically resect a Cholangiocarcinoma?
remove the half of the liver with the tumour
82
What are the differentials for pain swallowing?
- upper abdominal
- lower abdominal
- cardiac
- other
83
What are the causes of upper abdominal dysphagia?
- structural: pharyngeal cancer or puch
- neurological: parkinson's, stroke, motor neurone disease
84
What are the causes of lower abdominal dysphagia?
- structural: oesphogeal or gastric cancer, stricture, lung cancer
- neurological: achalasia, diffuse oesophageal spasm
85
What is the cardiac cause for difficulty swallowing?
Post-prandial angina
86
What is post prandial angina?
- angina which occurs after meals
- caused by blood shifting to bowel for digestion which limits blood supply through coronary arteries
- occurs on exertion
87
What symptoms differentiate upper and lower abdominal dysphagia?
- upper = pain on swallowing
- lower = easy swallowing but feels stuck seconds later
88
What indicates a neurological cause of dysphagia rather than mechanical?
Both solids and liquids are hard to swallow
89
What indicates a GI malignancy?
Blood in stool
90
What are the different types of microcytic anaemia?
MCV <80
1. Iron deficiency anaemia
2. Anaemia of chronic disease
3. Thalassaemia
4. Sideroblastic anaemia
91
What are the different types of normocytic anaemia?
MCV 80-96
Aplastic anaemia
Bleeding
Chronic disease
Destruction (haemolysis)
Endocrine disorders (hypothyroidism, hypoadrenalism)
92
What are the different types of macrocytic anaemia?
MCV >96
Foetus (pregnancy)
Alcohol excess
Thyroid disorders
Reticulocytosis
B12/Folate deficiency
Cirrhosis
93
What is iron deficiency anaemia caused by?
- increased demand
- decreased absorption
94
What are the GI causes of iron deficiency anaemia?
- aspirin/NSAIDs
- colonic adenocarcinoma
- gastric carcinoma
95
What is the main non-GI cause of iron deficiency anaemia?
Menstruation
96
What symptoms that might suggest colorectal cancer?
- Change in bowel habit
- Blood or mucus in stool
- Faecal incontinence
- Tenesmus
97
Symptoms that might suggest an upper GI cancer?
- Dysphagia
- Dyspepsia
98
What does Malena indicate?
upper GI bleeding
99
What does bright red PR bleeding indicate?
- lower GI bleeding
- haemorrhoids
100
What does blood and stool mixed indicated?
large colon issues
101
What tests would you do if colorectal cancer is suspected?
- Urine dipstick (haematuria?)
- Iron studies (confirm iron deficiency as the cause of microcytic anaemia)
- anti-TTG (coeliac screening)
- urgent colonoscopy through the 2-week-wait suspected cancer pathway. - - If negative, an upper GI endoscopy will be organised
102
What qualifies you for the 2-week wait suspected cancer colonoscopy?
blood in the stool
103
What tests need to be done to decide on a treatment plan for a descending colon adenocarcinoma?
- Staging CTCAP
(metastases picked up easily)
- MRI liver, pelvis
104
How do you manage a descending colon adenocarcinoma T3N0M1?
- resect primary colonic tumour/colonic stent
- neoadjuvant chemotherapy
- liver resection
105
What do NETs arise from?
Gastroenteropancreatic tract
106
What are NETs?
- diverse group of tumours
- all arise from the secretory cells of the neuroendocrine system
- secrete hormones
107
What are the causes of NETs?
- sporadic
- genetic (multiple endocrine neoplasia type 1)
108
What does multiple endocrine neoplasia type 1/MEN1 cause?
- parathyroid tumours
- pancreatic tumours
- pituitary tumours
109
What is the presentation of NETs?
- most are asympotmatic and found incidentally
- secretion of horomones and metabolites (serotonin, tachykinins, vasoactive peptides)
- carcinoid syndrome
110
What are the symptoms of carcinoid syndrome?
- vasodilaton
- bronchoconstriction
- increased intestinal motility
- endocardial fibrosis
111
What are the different types of NETs?
- insulinoma
- glucagonoma
- gastrinoma
- VIPoma
- somatostanioma
- non-functioning midgut tumour
- non-functioning hindgut tumour
112
How are NETs diagnosed?
- biochemical assessment
- imaging
113
What is screened for in a biochemical assessment?
- Chromogranin A (secretion of NETs)
- fasted gut hormones ( insulin, gastrin, somatostatin, PPY)
- calcium
- PTH
- prolactin
- GH
- serotonin metabolite 5-HIAA
114
What imaging is done for NETs?
- CT
- MRI
- (capsule) endoscopy
- barium flow through
- endoscopic US
- somatostatin receptor scintigraphy
115
What is the main treatment for NETs?
Curative resection
