GI cancers Flashcards
What is meant by primary and secondary cancers?
Primary-arising directly from cells within the organ
Secondary/Metastis- spread from another organs(
e.g from lymph into blood where it can then spread)
What are some of the cells of the GI Tract and what cancers can they give rise to?
EPITHELIAL CELLS:
Squamous -squamous cell carcinoma
Glandualar epithelium-Adenocarcinoma
NEUROENDOCRINE CELLS:
Enteroendocrine cells- Neuroendocrine tumours
Interstitual cells of Cajal- Gastrointestinal stromal tumours (GISTS)
CONNECTIVE TISSUE:
smooth muscle-Leiomyoma /leiomyosarcomas
Adipose tissues-liposarcomas
What are the 3 sections of the oesophagus and waht happens to the muscle as you go down the oesophagus?
Cervical Oesophagus
Middle Oesophagus
Lower oesophagus
As you go down the smooth muscle increases and skeletal muscle decreases
What are the 2 main types of cancer in the oesophagus
SQUAMOS CELL CARCINOMA:
- from normal oesphageal squamous epithelium
- upper 2/3 of oesophagus
- strongly related to alcohol as this gets oxidised via the acetaldehyde pathway
- More common in the less developed world
ADENOCARCINOMA:
- from metaplastic columnar epithelium
- lower 1/3 of the epithelium
- relted to acid reflux
- more common in the developed world
Describe how Adenocsarcinoma develops briefly?
1) 30% of the population has GORD(Gastro-oesophageal reflux disease) which causes OESOPHAGITIS(inflammation)
2) 5% of the GORD population get BARRETS where metaplasia of squamos cells to columnar epithelial cells occurs
3) This can develop into low grade dysplasia and then into high grade dysplasia and then into Adenocarcinoma(0.5-1% risk per year)
What are the guidelines of dealing with patients with Baretts?
No dysplasia-do OGD(where you view oesophagus through camera) every 2-3 years
Low grade dysplasia-every 6 months
High grade dysplasia-intervention so it doesnt turn into cancer
Which people are mostly effected by oesophageal cancer and what does this mean for survival?
-Elderly people, particularly men -means Survival rate is low (less than 20% survive 5 years) also complex surgery is involved which is more risky to the elderly
What are the symptoms of Oesophageal cancer?
can swallow-not even saliva
-this causes weight loss
What is the management pathway for Oesophageal cancer?
1) DIAGNOSIS- look down via endoscopy, take a biopsy and then look at the cells histalogically to identify cancer
2) STAGING- CT scan to see if the cancer has spread, LAPAROSCOPY-cut a hole underneath the belly button, blow it up with CO2 and put a camera in and look around peritoneum and liver to spot small things that the CT scan can’t, PET scan-give patient radioactive glucose as cancers absorb more glucose and then this shows u as light on the scan
3) TREATMENT PLAN-If you think its curable give NEO-ADJUVANT CHEMO(chemo before surgury) and then aim for radical surgery. PALLITVE TREATMENT-chemo, stent(opens up oesophagus), DXT
What surgey do you os on oesophageal cancer?
Oesophagectomy-via the IVOR LEWIS approach where you make an incosion in the uppe abdomen and remove the cncerous part of the oesophagus through this .
What is the most common GI cancer in western society?
What is the lifetime risk for men and women?
Who is effected by it?
Colorectal cancer
Men-1 in 10
Women-1 in 14
90% of causes affect people pver 50
In what froms do you get colorectal cancer?
SPORADIC-no fam history just a genetic mistake, isolated lesion
FAMILIAL- famiy history, effects <50, has to be a close 1st degree relative
HEREDITORY SYNDROME-family history, younger age of onset, multiple polips, specific gene defects
What are examples of hereditory syndrome colorectal cancers?
Familial adenomatous polyposis(FAP)
Hereditory nonpolyposis colorectal cancer(lynch syndrome)
Describe briefly the development of colorectal cancer?
Normal epithelium-> mutation occurs causing polip to develop which enetually turns into cancer
What are the rick factors of colorectal cancer?
Past history
Fmaily History (1st degree relative)
Diet/ environment- low fibre diet, smoking, obesity, carcinogenic foods
What are the comoon locations of colorectal cancer?
2/3 are in the descending xolon and rectum
1/2 are in the sigmoid colon and rectum
What are the ways you can look for colorectal cancer?
SIGMOIDOSCOPY- thinner tube but you only see as far as the spleenic flexture(most cancer picked up by this but should still do colonoscopy)
COLONOSCOPY-look at whole of large bowel
What are the clinical presentations of Caecal and right sided colorectal cancer?
- iron defficiency (anaemia)
- change of bowel habit(diarrhoea)
- Distal ilieum obstruction(late)
- palpabel mass(late)
What are the clincial presentations of left sided and sigmoid carcinoma ?(colorectal)
- PR bleeding
- mucus
- Thin stool (late)
What is the clinical presentations of Rectal carcinoma?
- PR bledding
- mucus
- anal, perineal, sacral pain
- tenesmus- feel like you need to go to the loo becuase you have a tumour pressing on your anal sphincter
- Bowel obrstuction(late)
What are symptoms of local invasion cancer vs metastasis cancer of colorectum?
Local invasion:
- bladder symptoms
- female genital tract symptoms
Metastasis:
- Liver(hepatic pain, jaundice)
- lung(cough)
- regional lymph nodes
- peritoneum
- sister Mary Joseph nodule( massive red growth in the belly button) happens in pancreatic and colorectalm cancers
What are signs of primary colorectal, cancer?
ABDOMINAL MASS:e.g.
Caecal tumour- feel something in ht eright of abdomen
Sigmoid tumour-fell something in the bottom left of adbomen
RIGID SIGMOIDOCOPY
ABDOMINAL TNDERNESS and DISTENSION
What are signs of secondary/ metastasis of Colorectal cancer?
HEPATOMEGALY- you can feel someones liver (shouldnt be able to)
BONE PAIN
MONOPHONIC WHEEZE
What investigations for colorectal cancer can you do?
FAECAL OCCULT BLOOD(Guaic test):
- checks for blood in stool based on pseudoperoxidase activity of haematin(component of haemoglobin)
- avoid red meat, melons, horse radish, vitamin C and NSAIDS for 3 days before the test
BLOOD TESTS:
FBC- anaemia, haematinics-low ferritin
Tumour markers- Monitor CEA (measure CEA before and after tumour is removed-it should go down significantly- monitor CEA every 6months and if it goes up something ain’t right)
DOUBLE CONTRAST BARIUM ENEMA:
- put barium up someones bum and dye in the small bowel and you will see aplly core type lesions in the GI Tract
- does not require sedation
- not as good at detecting smal, lesions
- all lesions to be confirmed with colonscopy and biopsy
- done in the past
COLONSCOPY:
-can visulaise lesion less than 5mm
- small polyps can then be removed(reduce cancer incidence)
- performed under sedation
CT COLONOSCOPY/CONOGRAPHY:
- can visualise lesions more than 5mm
- bowel has to be completely emptied first
- no need for sedation
- less invasive and better tolerated than colonoscopy
- if lesion identified then patinet needs colonscopy for diagnosis
What are other imaging tests used to investigate the spread of colorectal cancer?
MRI of pelvis:
- helps see the depth of invasion, metastasis
- can see lymph node involvement
- Non bowel prep or sedation required
- help choose between preoperative chemoradiotherapy or straight to surgery
CT of CHEST/ABDO/PELVIS:
-to identify the stge of the cancer prior to treatment
How do you manage a colorectal cancer?
It all depend on where in the colon the cancer is and what the blood suppliy to that area is like
RIGHT SIDED CANCER:
Tumour in CAECUM - remove the whole of the ascending colon RIGHT HEMICOLECTOMY
Tumour near the heaptic flexure- EXTENDED RIGHT HEMICOLECTOMY
LEFT SIDED CANCER:
Tumour in the left side- remove all the descending colon
Tumour in sigmid colon-remove the sigmoid colon
RECTAL CANCER:
blood supply is not very good here, os even if you try and conserve the blood supply leaks can occur(this is common)
What are the features of non resectable pancreatic cancer?
- 80-85% have late presentation( not good as it metastises early so cant stop it)
- median survial -less than 6 months
- 5 year survival 0.4-5%
- commonest form is pancreatic ductal andenocarcinoma(PDA)
What are the features of resectable pancreatic cancer?
- 15-20% of pancreatinc cancer have it
- means it can be removed with surgery
- median survival 11-20 months
- 20-25% survive upto 5 years
- virtually all dead within 7 years of surgery
What are some overall facts abour pancreatic cancer?
- hiher insidence in westinised countries
- rare before 40 years (80% occurance between ages 60-80)
Men> women (2:1)
- 4th commonest cause of cancer death
- incidence and mortality roughly equivalent
What are the risk factors of pancreatic cancer?
CHRONIC PANCREATITIS- 18 fold increased risk
Type 2 diabetes mellitus
- cholelithiasis, previous gastric surgery and pernicious anaemia(weak correlation)
- Diet(high fat and protein, low friut and veg)(weak correlation
-CIGARETTE SMOKING-causes 25-30%
-FAMILY HISTORY-in 7-10% of cases (relative risk increase 2fold if you have one effected relative, 6 fold if you have 2 relatives effected, 30 fold if you have 3 relatives effected)
INHERITED SYNDROMES -assosiated with increased risk e.g. Lynch syndrome, hereditory pancreatitus, FAP
What are the clinical presentations of cancer in the Head of the pancreas?
JAUNDICE(yellow ting to skin/whites of eyes):
- due to invasion or compression
- often painless
- palpabel gall badder(courvoisiers sign)
WEIGHT LOSS:
- anorexia
- malabsorption
- diabetes
PAIN:
- moves to the back in 25%
- 70% have thsi at the time of diagnosis
ACUTE PANCREATIS:
-in 5%
GASTROINTESTINAL BLEEDING:
-occasionally
What are clinical presentations of cancer in the body and tail of the pancreas?
- At diagnosis they are often more developed then lesion found in the head of the pancreas
- weight loos
- back pain in 60%
- jaundice is UNCOMMON
- vomiting sometimes occurs in late stage from invasion of the DJ flexure
- most are unresectabel(unremovable) at time of diagnosis
How does pancreatic cancer develop?
Start with non-invasive neoplastic lesion- Pancreatic intraepithelial Neoplasias (panIN)
these are less than 5mm and not visible from pancreatic imaging
They aquire clonally selected GENETIC and EPIGENETIC mutations along the way
Takes years to develop and often only detected when it metastisises
Which tumour marker helps you monitor pancreas cancer?
CA19-9:
- flasely elevated in pancreatitus, hepatic dysfuntion and obstructive jaundice
- not a good diagnostic tool
- good for monitoring as if you remove the tumour the levels get lower and shouldnt rise again
Wha tis the best way to startnidentifying if someone has tumour in pancreas(esp in yeloow people)?
ULTRASONOGRAPHY as it can identify:
- pancreatic cancers
- dilated bile ducts
- liver metastases
What is the best way to investigate if someone has pancreatic cancer?
DUAL PHASE CT:
- accurately predicts resectability in 80-90% of cases
- with contrast you can see the artereis and veins-which is important as this effects what you can and cant do
- can detect distant metastses
Why cant you don an operation on someone with jaundice straight away?
becuae they have high BILIRUBIN which increase the risk of renal failure so you have to be careful
Whart is an enderoscopic ultrasound
- telescope with camera on the need and ultrasound
- highly sensitve in the detection of small tumours
- can clearly see vascular innervation
How do you get rid of pancreatic cancer in the head of the pancrease?
remove head of pancreas, bile duct, Duodenum round to the DJ flexure, bottom end of the stomach
Then you have to join 3 things up: stomach, pancreas as pancrease juice has to go somewhere, and liver as bile juice has to go somewhere
How do you remove pancreatic cancer in the tail?
just remove the left side of the pancreas
What are the types of iver cancer?
Hepatocellular Carcinomas (HCC)-most common, primary liver cancer
cholangiocarcinoma(ChCA)- cancer in bile duct
Gallbladder Cancers-grow directly into the liver
Colorectal ccaner-most common cause of operation on the liver
What are the causes of hepatocellular carcinoma?
Most people have underlying Cirrohosis -where the liver does not function properly due to long term damage and scarring(fibrosis)
-This can be due to alcohol, hepatitus B etc
Aflatoxin-toxin produced in certain molds
What is treatment for Hepotocellular carcinoma?
- chemotherapy ineffectinve
- liver transplant(as removing tuour will just lead to another tumour as the liver is abnormal)
What is the survival rate of someone with Hepatocellular cancer with or without sugery?
Without: 5 yr survival less than 5%
With: 5 year survival more than 30%
however only 5-15% are suitable for surgery
What are the causes of Cholangiocarcinoma?
- Primary sclerosing cholangitis (PSC) is a chronic, or long-term, disease that slowly damages the bile ducts.
- UC(ulcerative collitus)
- LIVER FLUKE- parasites of the liver
- CHOLEDOCAL CYST
What are the treatments for Cholangiocarcinoma?
- Optimal is remove by surgery with curative intent
- but only 20-30% of patients are suitabel for surgery
- no other effective option
What is the survival rate of someone with Cholangiocarinoma before and after surgery?
Before: 5 year survival is less than 5%
After:20-40% survival
