GI 10 malignancy Flashcards by Alex Thompson

What are the common GI malignancies?

Oesophagus
Stomach
Large intestine
Pancreas
liver

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What % of malignancies in the UK are oesophageal carcinoma?

Male>female

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What are the clinical features of oesophageal carcinoma?

Dysphagia - progressively worsening

Weight loss

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What investigations are done to confirm a diagnosis of GI malignancy?

Endoscopy
Biopsy
Barium

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What are the pathological features of oesophageal carcinoma?

Squamous:
Most common
May occur at any level

Adenocarcinoma:
Uncommon
Lower 1/3
Association with Barrett’s oesophagus

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What is the presumed pathogenesis of squamous cell oesophageal carcinoma?

Progression through dysplasia

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Describe the pathogenesis of adenocarcinoma of the oesophagus.

Arises metaplastic epithelium of Barrett’s oesophagus
Progresses through dysplasia
Controversy over follow-up

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What is the prognosis of oesophageal carcinoma?

Advanced disease at presentation in most cases
Direct spread through oesophageal wall
Only 40% resectable
Many patients have a tube passed through tumour to facilitate swallowing
5% five year survival

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How common is gastric cancer and what is the prognosis?

15% of cancer deaths worldwide
Poor prognosis
5 year survival <20%

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Who is gastric cancer most common in?

Men > women
Japan
Associated with gastritis
Commoner in blood group A

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What are the clinical features of gastric cancer?

Symptoms often vague
Epigastric pain
Vomiting
Weight loss

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What are the macroscopic features of gastric cancer?

Fungating
Ulcerating
Infiltrative (linitis plastica)
Early

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What are the microscopic features of gastric cancer?

Intestinal - variable degree of gland formation

Diffuse - single cell and small groups, signet ring cells

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What are the differences in early and advanced gastric cancer?

Early - confined to mucosa/sub-mucosa, described in Japan, good prognosis
Advanced - Further spread, common in UK, <10% five year survival

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How does gastric cancer spread?

Direct
Lymph nodes
Trans-coelomic - peritoneum/ovaries
Liver

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What bacteria is associated with gastric cancer?

H. pylori - general association of chronic inflammation with cancer

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What is the most common GI lymphoma? Give some details.

Gastric lymphoma
Starts as low-grade lesion
Strong association with Hp
Eradication of Hp may lead to regression of tumour
Prognosis much better than gastric cancer

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Describe GI stromal tumours.

Uncommon
Derived from interstitial cells of Cajal
C-kit (CD117)
Specific targeted treatment
Unpredictable behaviour - pleomorphism, mitoses, necrosis

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What are the different types of tumours of the large intestine?

Adenomas
Ademocarcinomas
Polyps
Anal carcinoma

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What are the macroscopic and microscopic features of large intestinal adenomas?

Macro - sessile or pedunculated

Micro - variable degree of dysplasia

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What is the incidence of large intestinal adenomas?

Increase with age in western population
Genetic syndromes associated
Definite malignant potential

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What genetic conditions are associated with large intestinal adenomas?

Familial adenomatous polyposis - autosomal dominant, chromosome 5. Thousands of adenomas by 20ys. High risk of cancer
Gardner’s syndrome - similar to FAP. Bone and soft tissue tumours

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How are adenomas and carcinomas similar?

Geographical and anatomical distribution
Synchronous and metachronous lesions
Adenomas with invasion

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What are the macroscopic features of colorectal adenocarcinoma?

60-70% rectosigmoid
Fungating (esp right)
Stenotic (esp left)

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What are the microscopic features of colorectal adenocarcinoma?

Moderately differentiated | Occasionally mutinous and signet ring cell types present

How does colorectal adenocarcinoma spread?

Direct through bowel wall to adjacent organs e.g. bladder Via lymphatics to mesenteric lymph nodes Via portal venous system to liver

How is colorectal adenocarcinoma staged?

Duke's staging: A - confined to bowel wall B - through wall, lymph nodes clear C - Lymph nodes involved TNM

What genetic conditions are associated with colorectal adenocarcinoma?

FAP - chromosome 5 RAS mutations 18q (DCC) deletion 17p (p53) loss/inactivation

What is the incidence of colorectal adenocarcinoma?

peak 60-70 High UK/USA, low Japan Polyposis syndromes UC (and crohn's) associated

What is the aetiology of colorectal adenocarcinoma?

Low residue diet Slow transit time High fat intake Genetic predisposition

What are the likely outcomes for colorectal adenocarcinoma?

Survival reduces with increasing Duke's staging Liver metastases common in advanced disease Chemotherapy - palliative Resection of liver deposits gaining support Local radiotherapy for incompletely excised lesions

What are some other large intestinal tumours?

Carcinoid tumour - rare neuro-endocrine tumour, difficult to predict behavious Lymphoma - rare, may be primary or spread from elsewhere Smooth muscle/stromal tumours - rare and unpredictable

How is pancreatic carcinomaa diagnosed?

Imaging. Usually delayed, early symptoms vague -> weight loss, jaundice, Trousseau's sign

Describe the morphology of carcinoma of the pancreas

2/3 in head Firm, pale mass Cut surface - necrotic, haemorrhagic, cystic May infiltrate adjacent structures e.g. spleen

What is the histology of carcinoma of the pancreas?

80% ductal adenocarcinomas Well-formed glands +/- mucin Some acinar tumours containing zymogen granules All types have a poor prognosis

Describe the different islet cell tumours

``` Rare Insulinoma - hypoglycaemia Glucagonoma -> characteristic skin rash VIPoma -> Werner Morrison syndrome Gastrinoma -> Zollinger-Ellison syndrome ```

What are the different types of benign liver tumours?

Hepatic adenoma Bile duct adenoma/hamartoma Haemangioma

What are the different primary malignant liver tumours?

Hepatocellular carcinoma Cholangiocarcinoma Hepatoblastoma etc

What are the options for imaging the GIT?

``` Plain x-ray Contrast studies Ultrasound Cross-sectional imaging Angiography ```

What are the risks of using radiation?

Carcinogenesis Genetic Development risk of foetus

When would you request an abdominal x-ray?

Acute abdominal pain Small or large bowel obstruction acute exacerbation of IBD Renal colic

What are the features of an AXR?

Bowel pattern Soft tissue structures Bones

When is a part of a hollow tube visible in and AXR?

When gas filled - low density gas acts as a contrast | Fully fluid filled not visible

How are abnormal gas patterns viewed?

``` Small bowel obstruction >3cm Large bowel obstruction >6cm - competent ileocaecal valve (caecum >9cm), incompetent ileocaecal valve May be seen: in the ileum, volvulus toxic megacolon (rule of 3s - 3/6/9) ```

What is the presentation of a small bowel obstruction?

Vomiting (early) Distension (mild) Absolute constipation (late) Colicky pain

What are the causes of small bowel obstruction?

Adhesion Hernias Tumours Inflammation

What is the presentation of a large bowel obstruction?

Vomiting (late, faeculant) Distension (significant) Pain Absolute constipation

Wat are the causes of large bowel obstruction?

``` Colorectal carcinoma Diverticular stricture Hernia Volvulus Pseudo-obstruction ```

What is a volvulus?

Twisting around mesentery Enclosed bowel loop - dilates - perforation, ischaemia Sigmoid volvulus common, caecal uncommon

What are the classic signs of sigmoid volvulus on an AXR?

Coffee bean sign towards RUQ, dilation of proximal bowel

What are the classic signs of a caecal volvulus?

'mobile' caecum (20%) with mesentery

Can AXR be used to see inflammation and infection?

Yes but not god standard - will see: Mucosal thickening Featureless colon Bowel wall oedema

What is toxic megacolon?

Acute deterioration with UC or colitis Colon dilatation Oedema Pseudopolyps

What are the features of lead pipe colon?

featureless colon loss of hausfrau Chronic UC

What other abnormalities can be seen in AXR?

``` Stones Organs/masses Calcification - pancreatitis, vascular, nodes Bones Artefact Foreign body ```

What might cause perforation in the GIT?

``` Peptic ulcer Diverticular Tumour Obstruction Trauma Iatrogenic ```

What contrast studies are used to define hollow viscera?

Barium | Water soluble

What are the common GI contrast studies?

Swallowing Meal Follow through Enema

What is used for an abdominal CT scan?

High dose radiation IV or oral/rectal contrast Good spatial resolution

What does CT stand for?

computerized axial tomography

What does MRI stand for?

Magnetic resonance imaging

What are the pros and cons of MRI?

No radiation Good spatial and contrast resolution Time consuming

How does an ultrasound work?

Use of sound waves to generate image - frequency above audible range of human hearing Cheap, portable but highly dependent on user