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BRS YR2 > Gastrointestinal Cancers > Flashcards

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

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2
Q

What type of cancer tends to arise from squamous epithelial cells?

A

squamous cell carcinoma

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3
Q

What type of cancer tends to arise from glandular epithelial cells?

A

adenocarcinoma

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4
Q

What type of cancer tends to arise from enteroendocrine cells?

A

neuroendocrine tumours (NETs)

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5
Q

What type of cancer tends to arise from interstitial cells of Cajal cells?

A

Gastrointestinal Stromal Tumours (GISTs)

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6
Q

What type of cancer tends to arise from smooth muscle cells?

A

Leiomyoma/leiomyosarcomas

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7
Q

What type of cancer tends to arise from adipose tissue cells?

A

Liposarcomas

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8
Q

What population is most affected by colorectal cancer?

A

> 50 years old men

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9
Q

What is the most common GI cancer in the west?

A

Colorectal cancer

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10
Q

What are the different forms of colorectal cancer?

A
  • sporadic
  • familial
  • hereditary syndrome
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11
Q

What is the sporadic form of colorectal cancer?

A
  • Absence of family history
  • Older population
  • Isolated lesion
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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)
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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)
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14
Q

How do people with Familial adenomatous polyposis present?

A
  • young polyps
  • removals of lots of the large colon at a young age
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15
Q

What is thought to prevent the progression of polyps to colorectal cancers?

A

aspirin

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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
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17
Q

Where does colorectal cancer occur?

A
  • 2/3 - descending colon, rectum
  • 1/2 - sigmoid colon and rectum (seen on sigmoidoscopy)
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18
Q

How does caecal and right sided cancer present?

A
  • iron deficiency anaemia
  • diarrhoea
  • distal ileum obstruction (late)
  • palpable mass (late)
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19
Q

How does sigmoid and left sided cancer present?

A
  • PR bleeding
  • mucus
  • thin stools (late)
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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)
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21
Q

What are the late signs of local invasion of a carcinoma?

A
  • bladder symptoms
  • female genital tract symptoms
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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
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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)
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24
Q

What are the signs of metastasis and complications of colorectal cancer?

A
  • hepatomegaly
  • monophonic wheeze
  • bone pain
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25
Q

How do you diagnose colorectal cancer?

A
  • FIT (faecal immunochemical test) for occult blood
  • FBC: anaemia, haematinitcs, low ferritin
  • tumour markers: CEA (NOT a diagnostic tool)
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26
Q

How do you investigate colorectal cancer?

A
  • colonscopy
  • CT colonoscopy/colonography
  • MRI pelvis
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27
Q

Why is a colonscopy used to investigate colorectal cancer?

A
  • can visualize lesions <5mm
  • small polyps can be removed
  • reduced cancer incidence
  • performed under sedation
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28
Q

Why is a CT colonoscopy/colonography used to investigate colorectal cancer?

A
  • 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
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29
Q

Why is a MRI pelvis used to investigate colorectal cancer?

A
  • depth of invasion
  • mesorectal lymph node involvement
  • no bowel prep or sedation required
  • help choose between preop chemoradiotherapy or straight to surgery
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30
Q

What scans are used to stage a colorectal cancer prior to treatment?

A

CT chest/abdomin/pelvis

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31
Q

How do you manage an obstructing colon carcinoma in the right and transverse colon?

A
  • resection
  • primary anastomosis
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32
Q

How do you manage an obstructing colon carcinoma in the left sided colon?

A
  • Hartmann’s procedure (emergency operation)
  • Primary anastomosis
  • Palliative stent
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33
Q

What arteries supply the right and transverse colon?

A
  • Iliocolic
  • Right colic
  • Middle colic
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34
Q

What arteries supply the left sided colon?

A
  • branches of inferior mesenteric artery:
  • Left colic
  • sigmoid arteries
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35
Q

What happens in a Right Hemicolectomy?

A
  • right side of the large bowel
  • removing the ascending colon, caecum
  • connecting the terminal ileum, to the transverse colon
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36
Q

What happens in a Extended Right Hemicolectomy?

A
  • 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
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37
Q

What happens in a Left Hemicolectomy?

A
  • remove the descending colon
  • connect transverse colon to the sigmoid colon via anastomosis
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38
Q

How do you resect with rectal cancer?

A
  • remove the rectum and part of the sigmoid colon
  • connect the remaining colon (sigmoid) to the anus
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39
Q

What is normally done instead of a resection with rectal cancer?

A

iliostomy

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40
Q

What is the most common form of pancreatic cancer?

A

pancreatic ductal adenocarcimona

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41
Q

When does pancreatic cancer tend to present?

A
  • late (80-85%)
  • only 15-20% have resectable disease
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42
Q

When does pancreatic cancer tend to occur?

A

between 60-80 years of age

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43
Q

What are the risk factors of pancreatic cancer?

A
  • 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)
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44
Q

What are pancreatic intraepithelial neoplasias?

A
  • microscopic (<5mm)
  • not visible by pancreatic imaging
  • evolve through non-invasive neoplastic precursor lesions
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45
Q

What happens in the development of pancreatic ductal adenocarcinomas?

A

they acquire clonally selected genetic and epigenetic alterations along the way

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46
Q

How does a carcinoma at the head of the pancreas present?

A

(2/3)

  • Jaundice
  • Weight loss
  • Pain
  • acute pancreatitis
  • GI bleeding
  • vomiting
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47
Q

What causes jaundice with a carcinoma at the head of the pancreas?

A
  • invasion or compression of the common bile duct
  • painless
  • Courvoisier’s sign (palpable gallbladder)
48
Q

What causes weight loss with a carcinoma at the head of the pancreas?

A
  • anorexia
  • malabsorption (due to exocrine insufficiency)
  • diabetes
49
Q

What causes pain with a carcinoma at the head of the pancreas?

A
  • epigastrium
  • radiates to the back
50
Q

What does back pain with a carcinoma at the head of the pancreas indicate?

A
  • posterior capsule invasion
  • irresectability
51
Q

What does vomiting with a carcinoma at the head of the pancreas indicate?

A

duodenal obstruction

52
Q

What does GI bleeding with a carcinoma at the head of the pancreas indicate?

A
  • duodenal invasion
  • varices (due to portal or splenic vein occlusions)
53
Q

How does a carcinoma at the body and tail of the pancreas present?

A
  • asymptomatic at the early stages
  • weight loss
  • back pain
  • vomiting
  • unresectable at time of diagnosis
  • jaundice unlikely
54
Q

What does vomiting with a carcinoma at the body and tail of the pancreas indicate?

A

(late) - invasion of the DJ flexure

55
Q

What investigations can be done with pancreatic cancer?

A
  • Tumour marker: CA19-9
  • Abdominal ultrasound
  • Dual-phase CT
  • MRI
  • MRCP
  • ERCP
  • EUS
  • laparoscopy and laparascopic US
  • PET
56
Q

What does the Tumour marker: CA19-9 indicate?

A
  • falsely elevated in: pancreatitis, hepatic dysfunction and obstructive jaundice
  • conc. >200U/ml = 90% sensitivity
  • conc. > 1000 = high sensitivity
57
Q

What can an ultrasonography detect?

A
  • identify pancreatic tumours
  • dilated bile ducts
  • liver metastases
58
Q

What can a dual-phase CT detect?

A
  • accurately predict resectability in 80-90% of cases
  • contiguous organ invasion
  • vascular invasion (coeliac axis and SMA)
  • distant metastases
59
Q

What can an MRI detect?

A

detects and predicts resectability with accuracies similar to a CT

60
Q

What can an MRCP detect?

A

provides ductal images without ERCP complications

61
Q

What can an ERCP detect?

A
  • confirms the typical double duct sign
  • aspiration/brushing of the bile-duct system
  • therapeutic modality - biliary stenting to relieve jaundice
62
Q

What can an EUS detect?

A
  • highly sensitive in the detection of small tumours
  • assesses vascular invasion
  • FNA
63
Q

What can a laparoscopy and laparoscopic US detect?

A

radiologically occult metastatic lesions of liver and peritoneal cavity

64
Q

What can a PET detect?

A

demonstrates occult metastases

65
Q

When do you do a whipple resection?

A

when the carcinoma is at the head of the pancreas

66
Q

What is a whipple resection?

A
  • 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
Q

What is a TOP resection?

A

remove distal part of pancreas (tail and body), spleen

68
Q

What are the 4 different types of liver cancer?

A
  • Hepatocellular cancer
  • Cholangiocarcinoma
  • Gall Bladder cancers
  • Colorectal cancer liver metastases
69
Q

Where does hepatocellular cancer occur?

A

in the hepatocytes of the liver itself

70
Q

What can cause hepatocellular carcinoma?

A
  • cirrhosis (from alcohol or Hep B)
  • aflatoxin
71
Q

Where does Cholangiocarcinoma occur?

A
  • bile ducts, the bifurcation of the common hepatic duct
72
Q

How do you treat hepatocellular cancer?

A 
(chemo is ineffective)
Optimal is surgical excision with curative intent
- liver transplant
- transarterial haemoembolisation 
- radiofrequency ablation
73
Q

What is associated with gallbladder cancer?

A
  • gallstones
  • porcelain gall bladder
  • chronic typhoid infections
74
Q

How do you treat gallbladder cancer?

A
  • surgical excision with curative intent
  • chemo is ineffective
75
Q

What is the 5 year survival rate of gallbladder cancer?

A

stage 2: 64%
stage 3: 44%
stage 4: 8%

76
Q

What is thought to cause Cholangiocarcinoma?

A
  • choledochal cyst
  • ulcerative colitis and primary scloerosing cholangitis
  • liver flukes
77
Q

How do you treat Cholangiocarcinoma?

A

surgical excision with curative intent

78
Q

How do you treat secondary liver metastases?

A
  • surgical excision with curative intent
  • chemo improving
79
Q

How do you surgically resect a hepatocellular cancer?

A

remove the affected part of the liver (as little as possible)

80
Q

How do you surgically resect a gallbladder cancer?

A

remove the gallbladder, all the lymphnodes, liver tissue surrounding

81
Q

How do you surgically resect a Cholangiocarcinoma?

A

remove the half of the liver with the tumour

82
Q

What are the differentials for pain swallowing?

A
  • upper abdominal
  • lower abdominal
  • cardiac
  • other
83
Q

What are the causes of upper abdominal dysphagia?

A
  • structural: pharyngeal cancer or puch
  • neurological: parkinson’s, stroke, motor neurone disease
84
Q

What are the causes of lower abdominal dysphagia?

A
  • structural: oesphogeal or gastric cancer, stricture, lung cancer
  • neurological: achalasia, diffuse oesophageal spasm
85
Q

What is the cardiac cause for difficulty swallowing?

A

Post-prandial angina

86
Q

What is post prandial angina?

A
  • angina which occurs after meals
  • caused by blood shifting to bowel for digestion which limits blood supply through coronary arteries
  • occurs on exertion
87
Q

What symptoms differentiate upper and lower abdominal dysphagia?

A
  • upper = pain on swallowing
  • lower = easy swallowing but feels stuck seconds later
88
Q

What indicates a neurological cause of dysphagia rather than mechanical?

A

Both solids and liquids are hard to swallow

89
Q

What indicates a GI malignancy?

A

Blood in stool

90
Q

What are the different types of microcytic anaemia?

A

MCV <80
1. Iron deficiency anaemia
2. Anaemia of chronic disease
3. Thalassaemia
4. Sideroblastic anaemia

91
Q

What are the different types of normocytic anaemia?

A

MCV 80-96
Aplastic anaemia
Bleeding
Chronic disease
Destruction (haemolysis)
Endocrine disorders (hypothyroidism, hypoadrenalism)

92
Q

What are the different types of macrocytic anaemia?

A

MCV >96
Foetus (pregnancy)
Alcohol excess
Thyroid disorders
Reticulocytosis
B12/Folate deficiency
Cirrhosis

93
Q

What is iron deficiency anaemia caused by?

A
  • increased demand
  • decreased absorption
94
Q

What are the GI causes of iron deficiency anaemia?

A
  • aspirin/NSAIDs
  • colonic adenocarcinoma
  • gastric carcinoma
95
Q

What is the main non-GI cause of iron deficiency anaemia?

A

Menstruation

96
Q

What symptoms that might suggest colorectal cancer?

A
  • Change in bowel habit
  • Blood or mucus in stool
  • Faecal incontinence
  • Tenesmus
97
Q

Symptoms that might suggest an upper GI cancer?

A
  • Dysphagia
  • Dyspepsia
98
Q

What does Malena indicate?

A

upper GI bleeding

99
Q

What does bright red PR bleeding indicate?

A
  • lower GI bleeding
  • haemorrhoids
100
Q

What does blood and stool mixed indicated?

A

large colon issues

101
Q

What tests would you do if colorectal cancer is suspected?

A
  • 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
Q

What qualifies you for the 2-week wait suspected cancer colonoscopy?

A

blood in the stool

103
Q

What tests need to be done to decide on a treatment plan for a descending colon adenocarcinoma?

A
  • Staging CTCAP
    (metastases picked up easily)
  • MRI liver, pelvis
104
Q

How do you manage a descending colon adenocarcinoma T3N0M1?

A
  • resect primary colonic tumour/colonic stent
  • neoadjuvant chemotherapy
  • liver resection
105
Q

What do NETs arise from?

A

Gastroenteropancreatic tract

106
Q

What are NETs?

A
  • diverse group of tumours
  • all arise from the secretory cells of the neuroendocrine system
  • secrete hormones
107
Q

What are the causes of NETs?

A
  • sporadic
  • genetic (multiple endocrine neoplasia type 1)
108
Q

What does multiple endocrine neoplasia type 1/MEN1 cause?

A
  • parathyroid tumours
  • pancreatic tumours
  • pituitary tumours
109
Q

What is the presentation of NETs?

A
  • most are asympotmatic and found incidentally
  • secretion of horomones and metabolites (serotonin, tachykinins, vasoactive peptides)
  • carcinoid syndrome
110
Q

What are the symptoms of carcinoid syndrome?

A
  • vasodilaton
  • bronchoconstriction
  • increased intestinal motility
  • endocardial fibrosis
111
Q

What are the different types of NETs?

A
  • insulinoma
  • glucagonoma
  • gastrinoma
  • VIPoma
  • somatostanioma
  • non-functioning midgut tumour
  • non-functioning hindgut tumour
112
Q

How are NETs diagnosed?

A
  • biochemical assessment
  • imaging
113
Q

What is screened for in a biochemical assessment?

A
  • Chromogranin A (secretion of NETs)
  • fasted gut hormones ( insulin, gastrin, somatostatin, PPY)
  • calcium
  • PTH
  • prolactin
  • GH
  • serotonin metabolite 5-HIAA
114
Q

What imaging is done for NETs?

A
  • CT
  • MRI
  • (capsule) endoscopy
  • barium flow through
  • endoscopic US
  • somatostatin receptor scintigraphy
115
Q

What is the main treatment for NETs?

A

Curative resection

BRS YR2 (67 decks)

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