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Z YEAR 2 BRS GASTRO > GI cancers > Flashcards

GI cancers Flashcards

1
Q

What is cancer?

A

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems

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2
Q

What is a primary cancer?

A

Arising directly from the cells in an organ

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3
Q

What is secondary/metastasis cancer?

A

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

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4
Q

What are the six biological capabilities acquired by tumours?

A
  1. Sustaining proliferative signalling
  2. Evading growth suppressors
  3. Resisting cell death
  4. Inducing angiogenesis
  5. Enabling replicative immortality
  6. Activating invasion and metastasis
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5
Q

What are the emerging hallmarks?

A
  1. Deregulating cellular energetics

2. Avoiding immune destruction

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6
Q

What are enabling characteristics in the hallmarks of cancer?

A
  1. Genome instability and mutation

2. Tumour promoting inflammation

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7
Q

What type of disease is cancer?

A

genetic

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8
Q

What do cancers contain?

A

multiple genetic errors

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9
Q

Why is it hard to create cancer therapy?

A
  • Cancers contain more than just malignant cells
  • Killing cancer cells is easy
  • ONLY killing cancer cells is very hard
  • Developing novel therapies for cancer fraught with problems
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10
Q

What are the epithelial cells of the GI tract?

A

squamous “glandular epithelium”

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11
Q

What are the epithelial cell cancers of GI tract?

A
  1. Squamous cell carcinoma (SCC)

2. Adenocarcinoma

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12
Q

What are the neuroendocrine cells of the GI tract?

A
  1. Enteroendocrine cells

2. Intestinal cells of Cajal

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13
Q

What are the neuroendocrine cell cancers of the GI tract?

A
  1. Neuroendocrine tumours (NETs)

2. Gastrointestinal Stromal Tumours (GISTs)

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14
Q

What is the connective tissue of the cells of the GI tract?

A
  1. Smooth muscle

2. Adipose tissue

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15
Q

What are the cancers of GI tract with connective tissue?

A
  1. Liomyoma/leiomyosarcomas

2. Liposarcomas

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16
Q

What is cancer screening?

A
  1. Testing of asymptomatic individuals to identify cancer at an early stage
  2. What diseases are suitable for screening? Wilson & Jungner criteria.
  3. Depends on the epidemiology of a disease & features of the test.
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17
Q

What is involved in colorectal cancer GI cancer screening when offered to healthy individuals?

A
  1. Faecal immunochemical test (FIT) - detects haemoglobin in faeces, every 2 years for everyone aged 60-74
  2. One-off sigmoidoscopy for everyone aged >55 to remove polyps (reducing future risk of cancer).
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18
Q

In which patients do you carry out a regular endoscopy for oesophageal cancer screening?

A
  1. Barrett’s oesophagus

2. Low- or high-grade dysplasia

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19
Q

When do you carry out pancreatic and gastric cancer screening?

A
  1. No test exists that meets the W & J criteria

2. Depends on incidence - Japan screens for gastric cancer

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20
Q

When/How do you carry out hepatocellular cancer screening?

A
  • Regular ultrasound & AFP for high-risk individuals with cirrhosis
  • Viral hepatitis
  • Alcoholic hepatitis
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21
Q

When are there specific screening programmes for cancer?

A

or individuals with genetic predisposition or strong family histories

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22
Q

What is involved in the patient’s cancer journey?

A
  1. DIAGNOSIS
    What symptoms & signs does the patient present with?
    How is the diagnosis made
  2. STAGING
    What investigations are needed to see how advanced the cancer is?
  3. TREATMENT
    Can the cancer be surgically removed?
    What systemic therapy (e.g. chemotherapy) or radiotherapy is available?
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23
Q

What is involved in the initial presentation of cancer?

A
  1. The patient mentions worrying symptoms to their GP or another doctor (e.g. in A&E)
  2. The patient is identified through a screening programme (e.g. faecal occult blood test for colon cancer).
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24
Q

What happens after initial presentation?

A
  1. Patient is referred through the 2 week wait cancer pathway
  2. Diagnostic tests
  3. MDT
  4. Treatment
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25
Q

Who is in the cancer MDT?

A
  • Pathologist
  • Cancer nurse specialist (CNS)
  • Surgeon
  • Oncologist
  • Gastroentologist
  • Palliative care
  • radiologist
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26
Q

What does the pathologist do?

A
  • Confirms the diagnosis of cancer using biopsy samples.
    1. histological typing
    2. molecular typing
    3. tumour grade
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27
Q

What is histologic typing?

A

what type of cell does the cancer come from?

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28
Q

What are examples of histologic typing?

A

•Epithelium (squamous cell carcinoma) or secretory cells (adenocarcinoma).
•Non-epithelial cells less common in the GI tract.
1. Neuroendocrine tumours (pancreas)
2. Gastrointestinal stromal tumours (GISTS) – (stomach)

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29
Q

What is molecular typing?

A

what mutations does this cancer have?

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30
Q

Why is molecular typing important?

A

Alongside the histological type, this can determine types of treatment available

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31
Q

What is the tumour grade?

A

how aggressive is the cancer?

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32
Q

What is the tumour grade determined by?

A

Determined by how ‘abnormal’ cells & their nuclei are and how actively they are dividing

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33
Q

What does the radiologist do?

A
  1. Review scans
  2. Provides radiological tumours stage
  3. Provides re-staging after treatment
  4. Interventional radiology
34
Q

What does reviewing scans involve?

A
  • If diagnosis is unclear, comments on how likely the scan is to confirm cancer.
  • Suggests other imaging to clarify suspected diagnosis
  • Should a biopsy be performed and from where?
35
Q

What is the radiological tumour stage?

A

how far has the cancer spread?

36
Q

What are examples of radiological tumour stage?

A 
-The TNM system used. 
•T - size of Tumour.
•N - lymph Node involvement 
•M - presence of distant Metastases. 
-A T2N0M0 tumour may be totally curable, but a T3N1M1 may not be
37
Q

What does restaging after treatment involve?

A
  • Did the cancer respond completely or partially?

* Has it remained stable or progressed?

38
Q

What is interventional radiology?

A
  • Percutaneous biopsies

* Radiological stents

39
Q

What does the surgeon do?

A

-Decides whether surgery is appropriate.
•Is the tumour resectable?
•Is the patient fit enough for surgery?
-Performs operation & cares for patient in perioperative period

40
Q

What does a gastroenterologist do?

A

Endoscopy – diagnostic & therapeutic

41
Q

What does upper GI gastroenterologist do?

A
  • Oesophageal & gastric biopsies

* Oesophageal stents

42
Q

What does liver and pancreas gastroenterologist do?

A
  • ERCP & EUS biopsies

* Biliary stents

43
Q

What does lower GI gastroenterologist do?

A
  • Colonic biopsies

- Colonic stents

44
Q

What does the oncologist do?

A
  1. Decides on whether chemotherapy, radiotherapy or other systemic therapy is appropriate.
    •This is determined by the scans, histological and molecular type.
    •Is the patient fit for full intensity therapy?
  2. Coordinates the overall treatment plan
45
Q

What does the overall treatment plan involve?

A

Should chemotherapy come before surgery (neoadjuvant) or after (adjuvant)?
•Takes into consideration
-Type, grade & stage
-Patient fitness (‘performance status’) and wishes.

46
Q

What does the MDT decide?

A

-whether plan should be for radical (curative) or palliative therapy or palliative care
•Palliative care
•CNS

47
Q

What are the causes of gastric adenocarcinoma?

A
  • Chronic gastritis is the major driver
    1. H.pylori infection
    2. Pernicious anaemia
    3. Partial gastrectomy (e.g. for an ulcer)
    4. Epstein-Barr virus infection
    5. Family history (including heritable diffuse-type gastric cancer due to E-cadherin mutations)
    6. High salt diet & smoking
48
Q

Why does H pylori cause gastric adenocarcinoma?

A

chronic acid overproduction

49
Q

Why does pernicious anaemia lead to gastric adenocarcinoma?

A

autoantibodies against parts and products of parietal cells

50
Q

Why does the partial gastrectomy (e.g. for an ulcer) lead to gastric adenocarcinoma?

A

leading to bile reflux

51
Q

What is the pathogenesis of gastric cancer?

A
  1. Chronic gastritis
  2. Intestinal metaplasia
  3. Dysplasia
  4. Malignancy
52
Q

What is the commonest presentation for gastric cancer?

A

Dyspepsia (upper abdominal discomfort after eating or drinking)

53
Q

What are the ALARMS55 red flags?

A
  1. Anaemia
  2. Loss of weight or appetite
  3. Abdominal mass on examination
  4. Recent onset of progressive symptoms
  5. Melaena or haematemesis
  6. Swallowing difficulty
  7. 55 years of age or above
54
Q

How do you diagnose gastric cancer?

A

similar to oesophageal cancer: endoscopy + biopsy

55
Q

What is involved in the staging of gastric cancer?

A
  1. CT of the chest, abdomen & pelvis will provide information on distant lesions
  2. PET-CT
  3. Diagnostic laparoscopy - peritoneal & liver metastases disease prior to full operation
  4. Endoscopic ultrasound - will give most detail about local invasion & node involvement
56
Q

What are the treatment options for gastric cancer when tumours is at the oesophago-gastric junction?

A

oesophago-gastrectomy

57
Q

What are the treatment option when the tumour is close (<5cm) to the OG junction?

A

total gastrectomy (cannot save the sphincter mechanism)

58
Q

What are the treatment options when the tumour is further (<5cm) from OG junction?

A

subtotal gastrectomy

59
Q

What chemotherapy is used in gastric cancers?

A
  1. Neoadjuvant chemotherapy: may be used to reduce tumour size before surgery
  2. Adjuvant chemotherapy: may be needed in advanced tumours to reduce risk of relapse
60
Q

What are the palliative approaches for gastric cancer?

A

stenting or gastrojejunal anastomosis

61
Q

Where do NETs arise from?

A

gastroenteropancreatic (GEP) tract (or bronchopulmonary system)

62
Q

What are NETs?

A
  • Diverse group of tumours

* Regarded as common entity as arise from secretory cells of the neuroendocrine system

63
Q

What are NETs associated with?

A
  1. Sporadic tumours in 75%
  2. Associated with a genetic syndrome in 25%
    •Multiple Endocrine NeoplasiaType 1 (MEN1)which involves:
    •Parathyroidtumours
    •Pancreatic tumours
    •Pituitarytumours
64
Q

How are most NETs present?

A
  • Most NETs are asymptomatic and incidental findings

* < 10% of NETs produce symptoms

65
Q

What do NETs do?

A
  • Secretion of hormones & their metabolites in 40%

* serotonin, tachykinins (substance P) & other vasoactive peptides

66
Q

What are the debilitating effects that can result from NETs?

A 
-Carcinoid syndrome 
•Vasodilatation
•Bronchoconstriction
•↑ed intestinal motility
•Endocardial fibrosis (PR & TR)
67
Q

What are pancreatic NETs?

A
  1. Insulinoma

2. Glucagonoma

68
Q

What are the clinical features of insulinomas?

A
  1. Hypoglycaemia, Whipple’s triad

2. Beta cell

69
Q

What are the clinical features of glucagonoma?

A
  1. Diabetes mellitus, necrolytic migratory erythema

2. alpha cell

70
Q

What are pancreatic and duodenal NETs?

A

Gastrinoma

71
Q

What are the clinical features of gastrinoma?

A
  1. Zollingere-Ellison syndrome

2. G cell

72
Q

What are entire GIT NETs?

A
  • VIPoma

- Somatostatinoma

73
Q

What are the clinical features of VIPoma?

A
  1. Verner-Morrison syndrome, watery diarrhoea

2. VIP cell

74
Q

What are the clinical features of somatostatinoma?

A
  1. Gallstones, diabetes mellitus, steatorrhoea

2. D cell

75
Q

What are the clinical features of midgut NETs?

A

-Most are non-functioning -40% develop carcinoid syndrome

76
Q

What are the clinical features of NETs?

A

-Usually non-functioning

77
Q

What are the biochemical assessment of NETs?

A
  1. Chromogranin A is a secretory product of NETs
    2, Other gut hormones: insulin, gastrin, somatostatin, PPY
    -Measured in fasting state
  2. Other screening: Calcium, PTH, prolactin, GH
  3. 24 hr urinary 5-HIAA (serotonin metabolite)
78
Q

What is the imaging for NETS?

A 
•Cross-sectional imaging (CT and/or MRI)
•Bowel imaging (endoscopy, barium follow through, capsule endoscopy)
•Endoscopic ultrasound
•Somatostatin receptor scintigraphy
-68Ga-DOTATATE PET/CT most sensitive
79
Q

What are some treatment modalities for NETs?

A
  1. Curative resection (R0)
  2. Cytoreductive resection (R1/R2)
  3. Liver transplantation (OLTx)
  4. RFA, microwave ablation
  5. Embolisation (TAE), chemoembolisation (TACE)
80
Q

How can SIRT be used in NET treatment?

A
  • Selective Internal RadioTherapy (SIRT)

* 90Y-Microspheres

81
Q

How can Somatostatin receptor radionucleotide therapy be used in NET treatment?

A
  • 90Y-DOTA

* 177 Lu-DOTA

82
Q

How can Medical therapy, targeted therapy, biotherapy be used in NET treatment?

A
  • Octreotide, Lanreotide, SOM203
  • PK-inhibitors, mTOR-inhibitors
  • ⍺-Interferon

Z YEAR 2 BRS GASTRO (15 decks)

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