GI Cancers Flashcards
What are the cancers of the Epithelial cells?
Squamous “Glandular Epithelium” - Squamous cell carcinoma, Adenocarcinoma (most common).
What are the cancers of the Neuroendocrine cells?
Enterocendocrine cells - Neuroendocrine Tumours (NETs)
Interstitial cells of Cajal - Gastrointestinal Stromal Tumours (GISTs)
What are the cancers of Connective tissue?
Smooth muscle - Leiomyoma/leiomyosarcomas
Adipose tissue - Liposarcomas.
What type of muscle do you have in the oesophagus?
Skeletal
Skeletal/smooth
Smooth
Which type of Oesophageal cancer is more common in the less developed world?
Squamous Cell Carcinoma
From normal oesophageal squamous epithelium
Upper 2/3
Acetaldehyde pathway
What type of Oesophageal cancer is more common in the more developed world?
Adenocarcinoma
From metaplastic columnar epithelium
Lower 1/3 of oesophagus
Related to acid reflux
What percentage of the UK population have GORD?
30%
What is the pathway from Barret’s oesophagus to Adenocarcinoma?
Barrett’s oesophagus metaplasia
Dysplasia- low grade
Dysplasia- High grade
Adenocarcinoma
What are the guidelines for Barrett’s surveilance?
No dysplasia → Every 2-3 years
LGD → every 6 months
HGD → intervention
What is the ratio of male to female adencarcinoma of the oesophagus ratio?
M/F - 10:1
Who does Oesophageal cancer mainly affect?
Squamous- adenocarcinoma
9th most common cancer
Affects the elderly
What are the commonest presentations of Oesophageal cancers
Late presentation
- dysphagia & wt loss
65% palliative
High morbidity & complex surgery
Poor 5-year survival <20%
Palliation - difficultWhat is the management pathway for oesophageal cancer?
Diagnosis - Endoscopy -> Biopsy
Staging - CT scan, Lapraroscopy, PET scan, EndoscopicUltraSound EUS.
Treatment Plan;
Curative - Neoadjuvant chemo, Radical surgery.
Palliative - chemo, stent, DXT (radiotherapy)
What happens in an Oesophagectomy?
Two stage Ivor Lewis approach
Who is affected by Colorectal cancer?
Most common GI cancer in Western Societies
Third most common cancer death in men & women
Lifetime risk
1 in 10 for men
1 in 14 for women
Generally affects patients > 50 years (>90% of cases)
What are the different forms of Colorectal cancer?
Sporadic
Absence of family history, older population, isolated lesion
Familial
Family history, higher risk if index case is young (<50years) and the relative is close (1st degree)
Hereditary syndrome
Family history, younger age of onset, specific gene defects
e.g. Familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
Histopathology - Adenocarcinoma
What are the risk factors for Colorectal cancer?
Past history Colorectal cancer Adenoma, ulcerative colitis, radiotherapy Family history 1st degree relative < 55 yrs Relatives with identified genetic predisposition (e.g. FAP, HNPCC, Peutz-Jegher’s syndrome) Diet/Environmental ?carcinogenic foods Smoking Obesity Socioeconomic status
Where do colorectal cancers occur?
⅔ in descending colon and rectum
½ in sigmoid colon and rectum (i.e. within reach of flexible sigmoidoscopy)
How does a Caecal & right sided cancer present?
Iron deficiency anaemia (most common) Change of bowel habit (diarrhoea) Distal ileum obstruction (late) Palpable mass (late)
How does a Left sided & sigmoid carcinoma present?
PR bleeding, mucus, thin stool.
How does a Rectal Carcinoma present?
PR bleeding, mucus
Tenesmus (sensation you want to open bowels but nothing comes out)
Anal, perineal, sacral pain (late)
What are presentations of local invasion in colorectal cancer?
Bladder symptoms
Female genital tract symptoms
LATE
What are presentations of Metastasis in colorectal cancer?
Liver (hepatic pain, jaundice) Lung (cough) Regional lymph nodes Peritoneum Sister Mary Joseph nodule LATE
What are the signs of primary colorectal cancer?
Abdominal mass
DRE: most <12cm dentate and reached by examining finger
Rigid sigmoidoscopy
Abdominal tenderness and distension – large bowel obstruction
What are the signs of metastasis and complications in colorectal cancer?
Hepatomegaly (mets)
Monophonic wheeze
Bone pain
How do you diagnose colorectal cancer?
Faecal occult blood
Guaiac test (Hemoccult) – based on pseudoperoxidase activity of haematin
Sensitivity of 40-80%; Specificity of 98%
Dietary restrictions – avoid red meat, melons, horse-radish, vitamin C & NSAIDs for 3 days before test
FIT (Faecal Immunochemical Test) - detects minute amounts of blood in faeces (faecal occult blood).
What blood tests can you do in colorectal cancers?
Blood tests
FBC: anaemia, haematinics – low ferritin
Tumour markers: CEA which is useful for monitoring
good for monitoring evidence of post-operative recovery.
What can you do with a Colonoscopy?
Can visualize lesions < 5mm
Small polyps can be removed
Reduced cancer incidence
Usually performed under sedation
What can you do with a CT colonoscopy/colonography?
Can visualize lesions > 5mm
No need for sedation
Less invasive, better tolerated
If lesions identified patient needs colonoscopy for diagnosis
What are other imaging tests you would do i you suspect colorectal cancer?
MRI pelvis – Rectal Cancer
Depth of invasion, mesorectal lymph node involvement
No bowel prep or sedation required
Help choose between preoperative chemoradiotherapy or straight to surgery
CT Chest/Abdo/Pelvis
Staging prior to treatment
How is colorectal cancer primarily managed?
Surgery
What surgery is done for Right and transverse colon?
Resection & primary anastomosis
Better blood supply than the left
What is the surgery for Left sided obstruction?
Hartmann’s procedure Proximal end colostomy (LIF) \+/- Reversal in 6 months Primary anastomosis Intraoperative bowel lavage with primary anastomosis (10% leak) Defunctioning ileostomy Palliative stent
How common is Pancrratic Cancer?
Incidence ↑er in Western/industrialised countries
Rare before 45 years, 80% occur between 60 & 80 years of age
Men > women (1.5 - 2:1)
UK & USA annual incidence panc CA 100 per million popn
4th commonest cause of cancer death
Incidence & mortality roughly equivalent – UK in 2015
9,921 new cases of PDA
9263 deaths from PDA
2nd commonest cause of cancer death – in USA 2030
- 48,000 deaths
How does Chronic pancreatitis increase your risk of pancreatic cancer?
X18
How does Type 2 diabetes increase your risk of pancreatic cancer?
X1.8
What are some other risk factors for Pancreatic cancer?
Cholelithiasis, previous gastric surgery & pernicious anaemia – WEAK
Diet (↑fat & protein, ↓fruit & veg, coffee & EtOH) - WEAK
Occupation (insecticides, aluminium, nickel & acrylamide)
How does family history affect pancreatic cancer?
7-10% have a family history
Relative risk of PDA increased by: 2, 6 & 30-fold
with: 1, 2 & 3 affected first degree relatives
Inherited syndromes associated with a higher risk
How do Pancreatic Intraeptithelial Neoplasias PanIN’s develop?
PDAs evolve through non-invasive neoplastic precursor lesions
PanINs are microscopic (<5 mm diameter) & not visible by pancreatic imaging
Acquire clonally selected genetic & epigenetic alterations along the way
What are the stages of PanIN progression?
PanIN 1 - ERBB2, KRAS
PanIN 2 - CDKN2A
PanIN 3 - TP53, SMAD4, BRC2
How does carcinoma of the head of the pancreas present?
At least two-thirds of PDAs arise in the head
• Jaundice >90% due to either invasion or compression of CBD
- often painless
- palpable gallbladder (Courvoisier’s sign)
• Weight loss
- anorexia
- malabsorption (secondary to exocrine insufficiency)
- diabetes.
• Pain 70% at the time of diagnosis
- epigastrium
- radiates to back in 25%
- back pain usually indicates posterior capsule invasion and irresectability.
• 5% atypical attack of acute pancreatitis.
• In advanced cases, duodenal obstruction results in persistent vomiting.
• Gastrointestinal bleeding
- duodenal invasion or varices secondary to portal or splenic vein occlusion.
How does Carcinoma of the body of the pancreas develop?
Develop insidiously and are asymptomatic in early stages
At diagnosis they are often more advanced than lesions located in the head
There is marked weight loss with back pain in 60% of patients.
Jaundice is uncommon
Vomiting sometimes occurs at a late stage from invasion of the DJ flexure
Most unresectable at the time of diagnosis
What are the investigations for Pancreatic Cancer?
Tumour marker CA19-9
- falsely elevated in pancreatitis, hepatic dysfunction & obstructive jaundice.
- concentrations > 200 U/ml confer 90% sensitivity
- concentrations in the thousands associated with high specificity
• Ultrasonography
- can identify pancreatic tumours
- dilated bile ducts
- liver metastases
• Dual-phase CT accurately predicts resectability in 80–90% of cases
- contiguous organ invasion
- vascular invasion (coeliac axis & SMA)
- distant metastases
What imaging can be done for pancreatic cancer?
MRI imaging detects and predicts resectability with accuracies similar to CT
MRCP provides ductal images without complications of ERCP
• ERCP
- confirms the typical ‘double duct’ sign
- aspiration/brushing of the bile-duct system
- therapeutic modality → biliary stenting to relieve jaundice
What other imaging can be done for Pancreatic cancer?
EUS
- highly sensitive in the detection of small tumours
- assessing vascular invasion
- FNA
• Laparoscopy & laparoscopic ultrasound
- detect radiologically occult metastatic lesions of liver & peritoneal cavity
PET mainly used for demonstrating occult metastases
What surgeries can be done for Pancreatitis?
HOP Resesction - whipples
TOP Resection
What are the main types of Liver cancer?
Hepato cellular cancer HCC - cancer of the liver itself, usually occurs in patients with cirrhosis.
Cholangiocarcinoma ChCA - cancer of bile ducts, hylem most common place
Gall Bladder cancer - does not cause problems but spreads very quickly
Colorectal cancer liver metastisis.
What is the Aetiology of HCC?
Aetiology
- 70-90% have underlying cirrhosis
- Aflatoxin
Median survival without Rx 4-6 m
5yr survival <5%
Systemic chemotherapy ineffective (RR <20%)
Other effective Rx options
- OLTx - liver transplant
- TACE - trans arterial chemo embolisation
- RFA - radiofrequency ablation
Optimal Rx surgical excision with curative intent
- 5yr survival >30%
5-15% suitable for surgery
What is the Aetiology of Gallbladder cancer?
Aetiology unknown
- Gall Stones
- porcelain GB
- chronic typhoid infection
Median survival without Rx 5-8 m
5yr survival <5%
Systemic chemotherapy ineffective
No other effective Rx options
Optimal Rx surgical excision with curative intent
- 5yr survival: stage II 64%; stage III 44%; stage IV 8%
<15% suitable for surgeryWhat is the Aetiology of Cholangiocarcinoma ChCA?
Aetiology
- Primary Sclerosing Cholangitis & Ulcerative Colitis
- 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*
No other effective Rx options (OLTx)
Optimal Rx surgical excision with curative intent
- 5yr survival 20-40%
20-30% suitable for surgery
What is the Aetiology of Secndary liver metastases?
15-20% synchronous, 25% metachronous
median survival without Rx <1yr
5yr survival 0%
Systemic chemotherapy improving
Other effective Rx options (RFA & SIRT)
Optimal Rx surgical excision with curative intent
- 5yr survival rates of 25-50%
25% suitable for surgeryWhat are the causes of Upper dysphagia?
Structural - Pharyngeal cancer, Pharyngeal Pouch
Neurological - Parkinson’s, stroke, MND
What are the causes of Lower Dysphagia?
Structural;
Inside - oesopageal/ gastric cancer, stricture, Schatzki’s ring.
Outside - lung cancer
Neurological causes - Achalasia, diffuse oesophageal spasm
