GI Cancers Flashcards
- What does a ‘primary’ cancer mean?
- What does ‘secondary/metastasis’ mean when referring to cancers?
Cancer arising from cells in an organ
Spread from another organ, directly or by other means (blood, lymph)
- What are the 6 hallmarks of cancer?
Sustaining proliferative signalling
Resisting cell death Evading growth suppressors Inducing angiogenesis Activating invasion and metastasis Enabling replicative immortality
- What are the 2 ‘emerging’ and 2 ‘enabling’ hallmarks?
emerging - Deregulating cellular energetics, Avoidance of immune destruction
enabling - Tumour-promoting inflammation, Genome instability and mutation
- What cells are involved in Squamous Cell Carcinoma and Adenocarcinomas respectively?
- What cells are involved in Neuroendocrine Tumours and Gastrointestinal Stromal Tumours respectively?
- What cells are involved in Leiomyomas and Liposarcomas respectively?
Squamous cells, “Glandular epithelium”
Enteroendocrine cells, Interstitial cells of Cajal
Smooth muscle, Adipose tissue
- What is the most common cancer type in women?
- What is the most common cancer type in men?
- What is the most common cancer type involved in deaths?
Breast cancer
Prostate Lung cancer
- What is meant by a Cancer of Unknown Primary?
- Do pancreatic cancers tend to metastasise early?
- Which GI cancer has the largest overall 5-year survival rate?
Cancer where there is metastasis but you never find out where the primary has come from
Yes
Colorectal- 60%
- What are the 7 Wilson & Jungner criteria for cancer screening?
The condition sought should be an important health problem
There should be an accepted treatment for patients with recognised disease Facilitated for diagnosis and treatment should be available There should be a recognisable latent or early symptomatic stage There should be a suitable test or examination Test should be acceptable to the population The natural history of the condition , including development from latent to declared disease, should be adequately understood
- What are the 2 screening methods for colorectal cancer?
- How would you screen for oesophageal cancer?
Faecal immunochemical test (FIT) - detects haemoglobin in faeces, every 2 years for everyone aged 60-74
One-off sigmoidoscopy - for everyone aged >55 to remove polyps
Regular endoscopy to patients with: Barett's oesophagus, Low-high grade dysplasia
- How would you screen for pancreatic and gastric cancer?
- How would you screen for hepatocellular cancer?
No test exists that meets the W & J criteria, Depends on incidence - Japan screens for gastric cancer
Regular ultrasound and AFP (alpha-faeto protein found in high abundance in patients with this cancer) for high risk individuals with cirrhosis eg Viral hepaptitis, Alcoholic hepatitis
- What are the team members of a Cancer MDT?
Pathologist
Radiologist Cancer Nurse Specialist Palliative Care Gastroenterologist Oncologist Surgeon
- What do the pathologists do?
Confirm diagnosis of cancer using biopsy samples
Provide histologic typing - What type of cell does the cancer come from? Provide molecular typing - What mutations does the cancer have? Provide tumour grade - How aggressive is the cancer?
- What do the radiologists do?
Reviews scans - confirm diagnosis and gives possible diagnoses
Provides radiological tumour stage (TNN) - how far has the cancer spread Provides re-staging after treatment Interventional Radiology - Percutaneous biopsies and Radiological stents
- What does the surgeon do?
- What does the gastroenterologist do?
Decides whether surgery is appropriate
Performs operation and cares for patient in perioperative period
Endoscopy - diagnostic and therapeutic
- What does the oncologist do?
- what do the MDT ultimately decide together?
Decides on whether chemotherapy, radiotherapy or other systemic therapy is appropriate
Coordinates overall treatment plan - Should chemotherapy come before surgery (neoadjuvant) or after (adjuvant)?
MDT decides whether plan should be for radical (curative) or palliative therapy or palliative care
- Describe the pathogenesis of oesophageal cancer
Squamous cell carcinoma- Upper 2/3 and develop from normal oesophageal squamous epithelium
Adenocarcinoma - Lower 1/3 of oesophagus, Squamous epithelium that has become columnar (metaplastic) - Related to acid reflux
- How much of the population is affected by oesophagitis?
- What disease is oesophagitis a progression from?
- What condition does oesophagitis lead to?
30%
GORD - Gastro-oesophageal reflux disease Barett's Oesophagus (intestinal metaplasia)
- Describe the progression process of Barett’s oesophagus to cancer
- What do 0.5-11% patients with Barett’s per year then go on to have?
- What is meant by dysphagia?
Metaplasia → mild → moderate → severe dysplasia → cancer
Adenocarcinoma Difficulty swallowing (commonest symptom)
- Why is there late presentation of oesophageal cancer?
Significant cancer growth needs to occur before dysphagia develops
Often have metastases Most patients deemed unfit for surgery at diagnosis (malnourished)
- How would you diagnose oesophageal cancer?
Upper GI endoscopy (Oesophagogastroduodenoscopy, OGD)
Then biopsy it if a lesion is found
- Which investigations are used to stage the cancer?
CT of chest and abdomen
PET-CT scan to exclude metastases Staging laparoscopy - to identify liver and peritoneal metastases Endoscopic ultrasound - via oesophagus to clarify depth of invasion and involvement of local lymph nodes
- If the tumour is surgically resectable with no distant metastases and patient is fit enough to undergo major surgery, describe the treatment pathway followed?
- If not, describe the alternative treatment pathway that is followed for the patient?
Curative - Neoadjuvant chemotherapy followed by oesophagectomy
Palliative - palliative chemotherapy + steroids (dexamethasone - reduces oedema around tumour) + stents (to increase air flow)
- Describe the most common pathogenesis of gastric adenocarcinoma
Chronic gastritis is the major driver where most commonly H.pylori infection due to chronic acid overproduction
- Describe some of the other pathogeneses of gastric adenocarcinoma
Pernicious anaemia - autoantibodies against parts and products of parietal cells
Partial gastrectomy - leading to bile reflux Epstein-Barr virus infection Family history (including heritable diffuse type gastric cancer due to E-cadherin mutations) High salt diet and smoking
- Describe the progression from chronic gastritis to cancer?
Chronic gastritis → inflammation and atrophy → mucinous metaplasia → intestinal metaplasia (cells in stomach chnage to those lining intestinal cells) → dysplasia → cancer
- What is the most common symptom of gastric cancer?
- What are some of the ‘red flags’ that patients with gastric cancer tend to show?
Dyspepsia - Upper abdominal discomfort after eating or drinking
Anaemia
Loss of weight or appetite
Abdominal mass on examination
Recent onset of progressive symptoms
Melaena or haematemesis
Swallowing difficuly
55 years of age or above
- What investigations would you carry out to stage the gastric cancer?
CT of chest, abdomen and pelvis
PET-CT Diagnostic laparoscopy - peritoneal and liver metastases disease prior to full operation Endoscopic Ultrasound - gives most detail about local invasion and node involvement
- Why is neoadjuvant chemotherapy given to patients during treatment of gastric cancer instead of adjuvant?
It is used to reduce the tumour size before surgery and then reduce the chance of having metastases
also good to see how the tumour responds- if it responds aggressively better indication on whether surgery would work
- If the tumour is at the oesophago-gastric junction, what surgery will be needed?
- If the tumour is close (<5cm) to the OG junction, what surgery will be needed?
- If the tumour is further (>5cm) from the OG junction, what surgery is needed?
Oesophago-gasterectomy
Total gasterectomy - cannot save the sphincter mechanism Subtotal gasterectomy or distal gasterectomy
