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Gastroenterology > GI cancers > Flashcards

GI cancers Flashcards

1
Q

What is cancer?

A

A disease caused by an uncontrolled division of abnormal cells in a part of the body

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2
Q

What is primary cancer?

A

Arising directly from the cells in an organ

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3
Q

What is secondary/ Metastasis?

A

Spread from another organ, directly or by other means (blood or lymph)

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4
Q

What do you call a cancer arising from epithelial cell?

A
  1. Squamous: squamous cell carinoma (SCC)
  2. Glandular epithelium: Adenocarcinoma
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5
Q

What do you call a cancer arising from neuroendorine cells?

A
  1. Enteroendocrine cells: Neuroendocrine Tumours (NETs)
  2. Inerstitial cells of cajal (cells of circular muscle): Gastrointestinal Stromal Tumours (GISTs)
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6
Q

What do you call a cancer arising from connective tissue?

A
  1. Smooth muscle: Leiomyoma/leiomyosarcomas
  2. Adipose tissue: Liposarcomas
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7
Q

What is metaplasia?

A

A reversible change from one cell type into another cell type not normally found within that tissue

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8
Q

What is Dysplasia?

A

When cells within a tissue display abnormal features such as an enlarged nucleus, poorly differentiated, etc.

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9
Q

What are the red flag signs of cancer?

A

FLAWS
- Fever
- Lethargy
- Anorexia
- Weight loss
- Night sweats

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10
Q

What are the causes of colorectal cancer?

A
  1. Sporadic:
    - Most common
    - Generally in patient >50, older population
    - Absence of family history
    - isolated lesion
  2. Familial:
    - higher risk if index case is young (<50years)
    - Strong family history (eg. if first degree relative had it and was under 50
  3. Hereditary syndrome:
    - younger age of onset
    - Assoicated with specific gene defects
    e.g. Familial adenomatous polyposis (FAP)- most common, hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
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11
Q

What are the risk factors for colorectal cancer?

A
  1. Diet/Environmental
    - carcinogenic foods? red or processed meats
    - Smoking
    - Obesity
    - Poor Socioeconomic status
  2. Past history
    - Past Colorectal cancer
    - Adenoma
    - ulcerative colitis
    - Previous radiotherapy
  3. Family history:
    - 1st degree relative diagnosed with colorectal cancer < 55 yrs
    - Relatives with identified genetic predisposition
    (e.g. FAP, HNPCC (lynch syndrome), Peutz-Jegher’s syndrome)
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12
Q

What factor affects the clinical presentations of colorectal cancer?

A

Where in the colon it arises

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13
Q

What are the common presentations of caecal and right sided cancer?

A

Iron deficiency anaemia (most common)
Change of bowel habit (diarrhoea)

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14
Q

What are the late presentations of cecal and right sided cancer?

A

Distal ileum obstruction (late)
Palpable mass (late)

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15
Q

What are the common presentations of left sided and sigmoid cancer? (descending colon + sigmoid)

A

PR bleeding, mucus

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16
Q

What are the late presentations of left sided and sigmoid cancer?

A
  • Thin stool
  • Bowel obstruction
  • Palpable mass
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17
Q

What are the common presentations of rectal carcinoma?

A

PR bleeding, mucus
Tenesmus (feeling that you need to pass stools, even though your bowels are already empty)

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18
Q

What are the late presentations of rectal carcinoma?

A

Anal, perineal, sacral pain

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19
Q

Where in the colon do most colorectal adenocarcinomas arise?

A

sigmoid and rectum

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20
Q

What are the clinical presentations of metastasis of colorectal cancer?

A
  1. Right lymph nodes
  2. Lung metastases:
    - cough
  3. Liver metastases:
    - Hepatic pain
    - Jaundice
  4. Bone metastases:
    - Bone pain
  5. Metastases to peritoneum:
    Sister mary joseph nodule
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21
Q

What are the late clinical presentations of local invasion of colorectal carcinoma?

A

Bladder symptoms
Female genital tract symptoms

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22
Q

How would you diagnose colorectal cancer?

A
  • Bloods
  • Imaging
  • Guaiac test
  • FIT test
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23
Q

What are the signs of primary colorectal cancer?

A
  • Abdominal mass
  • DRE (digital rectal exam): most <12cm dentate and reached by examining finger
  • Rigid sigmoidoscopy
  • Abdominal tenderness and distension – large bowel obstruction
24
Q

Compare the rigid vs flexible sigmoidoscopy

A

Rigid:
- disposable
- No prep required
Flexible:
- Get more views
- Requires bowel prep

25
Q

What blood investigations are used to diagnose colorectal cancer?

A

FBC: anaemia, haematinics – low ferritin
Tumour markers: CEA (carcinoembryonic antigen- marker for colorectal cancer) which is useful for monitoring- NOT a diagnostic tool but aids diagnosis

26
Q

What imaging is used to diagnose colorectal cancer?

A

Colonoscopy: MUST look at the whole large bowel to come to a diagnosis- from the ileosecal valve
- Can visualize lesions < 5mm
- Small polyps can be removed:
* Reduced cancer incidence
- Usually performed under sedation

27
Q

What other special tests are used to diagnose colorectal cancer, other than bloods and imaging?

A
  1. Guaiac test (Hemoccult)
    - Dietary restrictions – avoid red meat, melons, horse-radish, vitamin C & NSAIDs for 3 days before test
  2. FIT (Faecal Immunochemical Test) - NEWER MAIN TEST detects minute amounts of blood in faeces (faecal occult blood).
28
Q

How do you stage colorectal cancer?

A
  • CT of chest, abdomen and pelvis (CT-CAP)- can detect metastases
  • Pelvis MRI- can detect extent of local tissue invasion, mesorectal lymph node involvement and can help guide appropriate treatment (choose between preoperative chemoradiotherapy or straight to surgery)
29
Q

How useful is a CT colonoscopy/colonography is the diagnoses of colorectal cancer?

A

NOT the main imaging:
No need for sedation
Less invasive, better tolerated BUT
Can only visualize lesions > 5mm
If lesions identified patient needs colonoscopy anyway for diagnosis

30
Q

How is colorectal cancer managed?

A

“Cut out cancer and stitch back up”
if it’s a right sided cancer:
- Right hemicolectomy (cut the cancerous part out)
- anastomosis of cut ends (join them together)
Left sided cancer:
- “Hartmann’s procedure”
- Left hemicolectomy (cut the cancerous part out)
- anastomosis of cut ends (join them together)

31
Q

How is colorectal cancer managed if the patient is too weak for surgery?

A

Palliative treatment:
- Palliative chemotherapy
- Stenting of bowel obstruction

32
Q

What is courvoisier’s law?

A

A
- painless
- palpable gallbladder
- with jaundice
… unlikely to be gallstones
- Should be assumed to be malignant until proven otherwise

33
Q

Describe the epidemiology of pancreatic cancer?

A
  • Relatively common & HIGHLY LETHAL
34
Q

What are the environmental risk factors for pancreatic cancer?

A
  • Smoking
  • Chronic pancreatitis
  • Type 2 diabetes mellitus
  • Occupational exposure (insecticides, aluminium, nickel & acrylamide)
  • Chronic pancreatitis
35
Q

What are the familial/ genetic risk factors of pancreatic cancers?

A
  • Family history (esp a first degree relative)
  • Hereditary pancreatitis
  • Familial atypical multiple mole melanoma (CDKNA2A mutation)
36
Q

Describe the pathophysiology of pancreatic cancer

A
  • Very linear progression- classical progression of cancer
  • PDA (pancreatic ductal adenocarcinomas) arise from an initial non-invasive lesion (precursor lesion)- these are known as Pancreatic Intraepithelial Neoplasias (PanIN)
    2. Liner progression in accumulation of oncogene and tumour suppressor mutations
    3. Eventual gain of functions enabling tumor survival and proliferation (eg. anigogenesis, immune evasion, limitless growth)
37
Q

What are the clinical signs and symptoms of a cancer in the head of the pancreas?

A

(2/3 of the pancreatic cancers)
- Painless jaundice + palpable gallbladder
- Duodenum obstruction -> vomiting and symptoms of bowel obstruction
- Weight loss and anorexia
- Epigastric pain (may radiate to back)
- Malabsorption
- New- onset diabetes

38
Q

What are the clincial signs and symptoms of a cancer in the tail of the pancreas?

A
  • Usually asymptomatic until very advanced
  • PC is usually weight loss + back pain
  • Vomiting may occur if duodenal compression occurs
  • Usually unresectable and very poor prognosis
39
Q

What bloods are used to investigate pancreatic cancer?

A

Blood testing for Tumour marker CA19
- Higher concentrations= higher sensitivity
- falsely elevated in pancreatitis, hepatic dysfunction & obstructive jaundice

40
Q

What imaging is used to diagnose pancreatic cancers?

A

Mainly:
- Abdominal ultrasound
- CT abdomen (useful for staging and can detect resectability)

  • Dual-phase CT (organ/ vascular invasion, predicts resectability, distant meastases)
  • Ultrasonography (can identify pancreatic tumours)
  • MRCP provides ductal images without complications of ERCP
  • ERCP (confirms the typical ‘double duct’ sign)
  • EUS (highly sensitive in the detection of small tumours)
  • Laparoscopy & laparoscopic ultrasound (detect radiologically occult metastatic lesions of liver & peritoneal cavity)
  • PET mainly used for demonstrating occult metastases
41
Q

How is cancer in the head of pancreas managed?

A

if resectable
- Pancreaticoduodenectomy (Whipple’s procedure)

42
Q

How is cancer is the tail of pancreas managed?

A

If resectable:
- Resection of tail of pancreas + spleen
- Splenic lumph node involvement warrants resection

43
Q

How is the pancreatic cancer managed if unresectable?

A

Unresectable= stages III or IV
- Palliative chemo+- radiotherapy
- Palliative stent insertion (endoscopic)

44
Q

What are the 4 types of liver cancers you can have?

A
  1. Hepatocellular cancer
  2. Gallbladder cancer
  3. Cholangiocarcinoma
  4. Colorectal cancer- secondary liver metastases
45
Q

What is the cause of gallbladder cancer?

A
  • Unknown, thought to be:
  • Gallstones
  • porcelain gallbladder
  • chronic typhoid infection
46
Q

What is management for gallbladder cancer?

A

Optimal treatment is radical surgical excision

47
Q

What is the cause of Cholangiocarcinoma?

A
  • Primary Sclerosing Cholangitis (PSC), associated with ulcerative colitis (UC)
  • Liver fluke
  • Choledochal cyst
48
Q

How is cholangiocarcinoma managed?

A
  • Optimal treatment is radical surgical excision
  • GemCis chemotherapy regimen
49
Q

What is the management for secondary liver metastases (colorectal)

A
  • Systemic chemotherapy
  • Radiofrequency ablation
  • Selective internal radiotherapy (SIRT)- also known as trans-arterial radioembolization (TARE)
  • Surgical excision
50
Q

What is the cause of hepatocellular carcinoma (HCC)

A
  • Aflatoxin (toxin found in Aspergillus species)
51
Q

What is the management of hepatocellular carcinoma (HCC)

A
  • Radical surgical excision
  • Radiofrequency ablation
  • Trans- arterial Chemoembolization (TACE)
52
Q

What are neuroendocrine tumours?

A

Arise from the gastroenteropancreatic (GEP) tract (or bronchopulmonary system)
- Diverse group of tumours
- Regarded as common entity as arise from secretory cells of the neuroendocrine system

53
Q

What is the cause of neuroendocrine tumours?

A
  1. Sporadic
  2. Associated with a genetic syndrome in 25%
    - Multiple Endocrine NeoplasiaType 1 (MEN1)
    * Parathyroidtumours
    * Pancreatic tumours
    * Pituitarytumours
54
Q

What are the clinical presentations of neuroendocrine tumour?

A
  • Most NETs are asymptomatic & incidental findings
  • < 10% of NETs produce symptoms (can result in a variety of debilitating effects):
  • The liver efficiently metabolises serotonin released into the portal circulation.
  • Therefore carcinoid syndrome seldom (tumour releases serotonin/ 5-HT and other metabolites) occurs in the absence of metastatic liver deposits.
  • Carcinoid syndrome=
  • Vasodilatation
  • Bronchoconstriction
  • ↑ed intestinal motility
  • Endocardial fibrosis (PR & TR)
55
Q

How are neuroendocrine tumours diagnosed?

A

investigations to localise the tumour & confirm the diagnosis with histology
- Chromogranin A is a secretory product of NETs (BEST OPTION)
- Screening: calcium, PTH, somatostatin, PPY
- Cross-sectional imaging (CT and/or MRI)
- Bowel imaging (endoscopy, barium follow through, capsule endoscopy)
- Endoscopic ultrasound
- Somatostatin receptor scintigraphy
- 68Ga-DOTATATE PET/CT (V.GOOD AT FINDING TUMOURS)

56
Q

How are neuroendocrine tumours graded?

A

Grade Mitoses Ki-67 Index
G1 <2/10 H.P.F. </= 2%
G2 2-20/10 H.P.F. 3-20%
G3 >20/10 H.P.F. >20%
(High Grade (Poorly Differentiated) Neuroendocrine Carcinoma)

57
Q

What are the treatment options for a neuroendocrine tumour?

A

MAIN OP: Curative resection (R0)

  • Cytoreductive resection (R1/R2)
  • Liver transplantation (OLTx)
  • RFA, microwave ablation
  • Embolisation (TAE), chemoembolisation (TACE)
  • Selective Internal RadioTherapy (SIRT)
  • Somatostatin receptor radionucleotide therapy
  • Medical therapy, targeted therapy, biotherapy

Gastroenterology (9 decks)

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