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9. GI system > GI cancers (Oesophageal, Gastric, Large bowel) > Flashcards

GI cancers (Oesophageal, Gastric, Large bowel) Flashcards

1
Q

What are 2 main types of oesophageal cancers?

A
  1. Oesophageal adenocarcinoma
  2. Squamous cell carcinoma
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2
Q

Where are oesophageal adenocarcinomas located?

A

Lower ⅓ of the oesophagus
and at the cardia

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3
Q

Where are squamous cell carcinomas located?

A

Upper ⅔ of the oesophagus

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4
Q

Which type of oesophageal cancer is found more common in the developed world?

A

Oesophageal adenocarcinomas

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5
Q

Which type of oesophageal cancer is found more common in the developing world?

A

Squamous cell carcinomas

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6
Q

What cells normally line the oesophagus?

A

Stratified squamous non-keratinising cells.

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7
Q

What is Barrett’s oesophagus?

A

When squamous cells undergo metaplastic changes and become columnar cells.

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8
Q

Give a potential consequence of Barrett’s oesophagus.

A

Adenocarcinoma.

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9
Q

Define adenocarcinoma.

A

A malignant tumour of glandular epithelium.

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10
Q

Give 3 causes of oesophageal adenocarcinoma.

A
  1. GORD -> Barrett’s (premalignant).
  2. Smoking and tobacco.
  3. Obesity.
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11
Q

Give 3 risk factors for oesophageal adenocarcinomas.

A
  • Alcohol
  • Smoking
  • Obesity - since increased reflux
  • Achalasia
  • Obesity
  • Diet low in Vitamin A & C
  • Barrett’s oesophagus
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12
Q

What lymph nodes can oesophageal adenocarcinoma commonly metastasise to?

A

Para-oesophageal lymph nodes.

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13
Q

Give 3 causes of squamous cell carcinoma.

A
  1. Smoking.
  2. Alcohol.
  3. Poor diet.
  4. Achalasia (disorder where oesophagus has reduced/no ability to do peristalsis and transport food down)
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14
Q

Give 5 symptoms of oesophageal cancers.

A

Symptoms often present very late.

  1. Progressive Dysphagia (solids followed by liquids)
    -> RED FLAG
  2. Odynophagia (painful swallowing).
  3. Weight loss
  4. Anorexia
  5. Hoarse voice (pressing on recurrent laryngeal nerve)
  6. Red flags (ALARMS)
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15
Q

What investigations might you do in someone who you suspect to have oesophageal cancer?

A
  1. Oesophagoscopy/Upper GI endoscopy with biopsy:
    * To confirm diagnosis with histological proof of carcinoma
  2. CT-TAP/MRI of the chest and abdomen
    * For tumor staging and metastases
    * PET is more sensitive in detecting metastases
  3. Barium swallow
    * To see strictures
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16
Q

Criteria for 2-week endoscopy referral.

A

2-week endoscopy referral in people with:

  1. Dysphagia or
  2. Age ≥ 55 YO with weight loss and 1 of the following:
    • Upper abdominal pain
    • Reflux
    • Dyspepsia
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17
Q

Describe the 2 treatment options for oesophageal cancer.

A
  1. Medically fit and no metastases = operate. The oesophagus is replaced with stomach or sometimes the colon. The patient often has 2/3 rounds of chemo before surgery.
  2. Medically unfit and metastases = palliative care. Stents can help with dysphagia.
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18
Q

What is the management for oesophageal cancer?

A
  1. Surgical resection with adjuvant radiotherapy/ chemotherapy
    - Best chance of cure if tumour has not infiltrated outside the
    oesophageal wall (stage 1)
    - Combined with chemotherapy (neoadjuvant chemotherapy) BEFORE SURGERY (improves outcomes) +/- radiotherapy
  2. Treat dysphagia using stents via endoscopy
    - Endoscopic insertion of expanding metal stent across tumour to
    ensure oesophageal patency
    - Laser and alcohol injections to cause tumour necrosis and increase lumen size
  3. Palliative care (5-year prognosis is 25%)
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19
Q

Differential diagnosis for oesophageal cancer.

A

Differentials:
1. Achalasia
2. Strictures
3. Barrett’s oesophagus

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20
Q

What are 2 types of gastric cancer?

A
  1. Type 1 (Intestinal)
  2. Type 2 (Diffuse)
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21
Q

Give 3 causes of gastric cancer.

A
  1. Smoking
  2. Helicobacter pylori infection.
  3. Dietary factors e.g. high salt and nitrates
  4. Loss of p53 + APC genes
  5. Pernicious anaemia.
  6. Fx/Genetic - First degree relative with gastric cancer - CDH1 gene
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22
Q

Which type of gastric cancer is more prevalent?

A

Type 1 (Intestinal) = 80% prevalence

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23
Q

Which type of gastric cancer has a better prognosis?

A

Type 1 (Intestinal)

Type 2 (Diffuse) = worse prognosis = 5-year survival of 3-10%

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24
Q

Where would you find type 1 gastric cancer?

A

Antrum + lesser curvature.
More likely to involve the distal stomach.

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25
Q

Where would you find type 2 gastric cancer?

A

Diffuse because it affects anywhere in the stomach, especially the cardia.

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26
Q

Which type of gastric cancer has a strong environmental association?

A

Type 1 (intestinal).

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27
Q

A mutation in what gene can cause familial diffuse gastric cancer?

A

CDH1 - 80% chance of gastric cancer.
(Prophylactic gastrectomy is done in these patients.)

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28
Q

Which type of gastric cancer is more well formed and differentiated?

A

Type 1 (Intestinal).

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29
Q

Explain the pathophysiology of type 1 (intestinal) gastric cancer.

A

Normal gastric mucosa → H.pylori infection → ACUTE GASTRITIS → Chronic active gastritis → Atrophic gastritis → Intestinal metaplasia → DYSPLASIA → ADVANCED GASTRIC CANCER

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30
Q

Explain the pathophysiology of type 2 (diffuse) gastric cancer.

A

Development of linitis plastica (leather bottle stomach)
= the thickening and rigidity of the stomach wall.

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31
Q

Describe how gastric cancer can develop from normal gastric mucosa.

A

Smoked/pickled food diet leads to intestinal metaplasia of the normal gastric mucosa. Several genetic changes lead to dysplasia and then eventually intra-mucosal and invasive carcinoma.

32
Q

What can be seen for type 2 (diffuse) gastric cancer histologically?

A

Signet ring cells

33
Q

Give 4 risk factors for type 1 (intestinal) gastric cancer.

A
  1. Male
  2. Older age
  3. H.pylori infection
  4. Chronic / Atrophic gastritis
34
Q

Give 4 risk factors for type 2 (diffuse) gastric cancer.

A
  1. Female
  2. Younger age (<50 YO)
  3. Blood type A
  4. Genetic
  5. H.pylori infection
35
Q

Give 5 signs + symptoms of gastric cancer.

A

Most patients with carcinoma of the stomach have advanced disease at the time of presentation.

  1. Virchow’s node (left supraclavicular)
    - Something to do with how lymph nodes drain
  2. Weight loss
  3. Nausea & Vomiting
  4. Haematemesis/melena
  5. Dysphagia
  6. Anorexia
  7. Epigastric pain (indistinguishable from peptic ulcer disease)
  8. Red flags (ALARMS)
36
Q

What is Virchow’s node?

A

Palpable lymph node in supraclavicular fossa - Virchow’s node - usually on the left side

37
Q

What investigations might you do in someone who you suspect has gastric cancer?

A
  1. Upper GI endoscopy + biopsy
    -To histologically confirm adenocarcinoma
  2. Endoscopic ultrasound
    - To evaluate the depth of invasion
    - To detect nodal involvement prior to surgery
  3. CT/MRI for staging
  4. PET scan to identify metastases
38
Q

What is the advantage of doing a laparoscopy in someone with gastric cancer?

A

It can detect metastatic disease that may not be detected on ultrasound/endoscopy.

39
Q

What is the treatment for proximal gastric cancers that have no spread?

A

3 cycles of chemo and then a full gastrectomy. Lymph node removal too.

40
Q

What is the treatment for distal gastric cancers that have no spread?

A

3 cycles of chemo and then a partial gastrectomy if the tumour is causing stenosis or bleeding. Lymph node removal too.

41
Q

Management for gastric cancers.

A
  1. Nutritional support
  2. Surgical resection and combination chemotherapy
    - Subtotal or total gastrectomy
    - EPIRUBICIN + CISPLATIN + 5- FLUOROURACIL known as ECF chemo (given around same time as surgery) and post-op radiotherapy
  3. Palliative care
  4. Supportive care
42
Q

What vitamin supplement will a patient need following gastrectomy?

A

They will be deficient in intrinsic factor and so will need vitamin B12 supplements to prevent pernicious anaemia.

43
Q

Give 3 indications for OGD.

A
  1. Dyspepsia.
  2. Dysphagia.
  3. Anaemia.
  4. Suspected coeliac disease.
44
Q

Give 2 potential complications of oesophago-gastroduodenoscopy (OGD) / gastroscopy.

A
  1. Cardiopulmonary.
  2. Small risk of bleeding or perforation.
45
Q

Where would bowel cancer be found most commonly?

A

Most common in the sigmoid colon and rectum.

46
Q

What is a colonic polyp?

A

A colonic polyp is an abnormal growth of tissue projecting from the colonic mucosa.

47
Q

What is an adenoma?

A

Adenomas are the precursor lesion in MOST cases of COLON CANCER.

They are a benign, dysplastic tumour of columnar cells or glandular tissue.

48
Q

How can adenoma formation be prevented?

A

NSAIDS are believed to prevent adenoma formation.

49
Q

What is the treatment for adenoma?

A

Endoscopic resection.

50
Q

What is the treatment for polyps?

A

Removed at colonoscopy to reduce development into cancer risk

51
Q

What are the 2 types of inherited polyps?

A
  1. Familial adenomatous polyposis (FAP)
  2. Lynch syndrome (Hereditary Non-Polyposis Colon Cancer (HNPCC))
52
Q

What is familial adenomatous polyposis (FAP)?

A

Autosomal dominant condition arising from a mutation in the APC gene.

  • Characterised by the presence of 100s - 1000s of colorectal + duodenal polyps in your teens.
53
Q

Describe the pathophysiology of familial adenomatous polyposis (FAP).

A

There is a mutation in APC protein and so the APC/GSK complex isn’t formed -> beta catenin levels increase -> up-regulation of adenomatous gene transcription.

54
Q

What is Lynch syndrome (Hereditary Non-Polyposis Colon Cancer (HNPCC))?

A

Autosomal dominant condition caused by a mutation in one of the DNA mismatch repair genes, usually hMSH2 or hMSH1.

Polyps are formed in the colon and may rapidly progress to colon
cancer.

55
Q

Describe the pathophysiology of HNPCC.

A

There are no DNA repair proteins meaning there is a risk of colon cancer and endometrial cancers.

56
Q

Give 4 risk factors for bowel cancer.

A
  1. FHx
  2. Genetic/Inherited
  3. IBD
  4. Obesity
  5. DM
  6. Smoking
  7. Alcohol
  8. Increasing age
57
Q

Where is majority of bowel cancer found?

A

MAJORITY IN DISTAL COLON:
In the descending/sigmoid colon and rectum.

  • The closer the cancer is to the outside the more visible blood and mucus will be.
58
Q

Give 3 signs of a right sided cancer/carcinoma.

A

Usually asymptomatic until they present with iron deficiency anaemia due to bleeding.

  1. Anaemia with low Hb
  2. May present with a mass
  3. Weight loss
  4. Abdominal pain
  5. Diarrhoea that doesn’t settle
59
Q

Give 3 signs of a left sided/sigmoid carcinoma.

A
  1. Change of bowel habit e.g. diarrhoea, constipation, alternation between them
  2. Blood and mucus in stools
  3. PR bleeding
60
Q

Give 3 signs of rectal cancer.

A
  1. PR (rectal) bleeding.
  2. Mucus.
  3. Thin stools (when cancer grows).
  4. Tenesmus (feeling to keep having to go empty your bowels).
61
Q

What can affect the clinical presentation of a bowel cancer?

A

How close the cancer is to the rectum affects its clinical presentation.

62
Q

Why do proximal colon cancers have a worse prognosis?

A

They have fewer signs and so people often present with them at a very advanced and late stage.

63
Q

Emergency presentation signs.

A

Obstruction (20%):
- 4 cardinal signs of obstruction:
* Absolute constipation
* Colicky abdominal pain
* Abdominal distension
* Vomiting (faeculent)

64
Q

Describe the emergency presentation of a left sided colon cancer.

A

The LHS of the colon is narrow and so the patient is likely to present with signs of obstruction e.g. constipation; colicky abdominal pain; abdominal distension; vomiting.

65
Q

Describe the emergency presentation of a right sided colon cancer.

A

The RHS of the colon is wide and so the patient is likely to present with signs of perforation.

66
Q

What investigations might you do in someone who you suspect might have bowel cancer?

A
  1. Gold standard: Colonoscopy + biopsy
    - It permits biopsy and removal of small polyps.
  2. Sigmoidoscopy (rectum and sigmoid colon)
  3. CT colonography (if unfit for colonoscopy)
  4. CT TAP (thorax, abdomen and pelvis) for staging (Duke’s classification, TNM classification)
    - ALWAYS get this if the biopsy is positive for staging!!
  5. Tumour markers - Carcinoembryonic antigen (CEA)
    - Good for monitoring progress
67
Q

What is the screening for bowel cancer and who is eligible?

A

Bowel cancer screening for 60-74yo, every 2 years
Faecal Immunochemical test (FIT) = faecal occult blood

68
Q

Give 3 indications for colonoscopy.

A
  1. Altered bowel habit.
  2. Diarrhoea +/- dysentery.
  3. Anaemia.
69
Q

What is Duke’s classification?

A

Dukes Classification (older):
- A = limited to muscularis mucosae – 95% 5 yr survival
- B = Extension through muscularis mucosae (not lymph) – 75%
- C = Involvement of regional lymph nodes – 35%
- D = Distant metastases – 6.6%

70
Q

What is the TNM system for classification?

A
  • T
  • Refers to the primary tumour and is suffixed by a number that
    denotes tumour size
  • The number varies according to the organ harbouring the
    tumour
  • N
  • Refers to lymph node status and is suffixed by a number that
    denotes the number of lymph nodes or groups of lymph nodes
    containing metastases
  • M
  • Refers to the anatomical extent of distant metastases
71
Q

Treatment for colorectal adenocarcinoma (bowel cancer).

A
  1. Surgical resection can be done ONLY when there is no spread!
    Remember to balance risks v benefits.
    The patient has a pre-op assessment.
  2. Endoscopic stenting
  3. Radiotherapy
  4. Chemotherapy
72
Q

What are the different open surgeries for bowel cancers depending on their location?

A
  • Right sided – right hemicolectomy
  • Transverse colon – extended right hemicoectomy
  • Left sided – left sided hemicolectomy
  • Sigmoid – Sigmoid colectomy
  • Low Sigmoid, high rectal – Anterior resection
73
Q

What is the treatment for metastatic colorectal adenocarcinoma?

A

Chemotherapy and palliative care.

74
Q

Give 3 reasons why bowel cancer survival has increased over recent years.

A
  1. Introduction of the bowel cancer screening programme.
  2. Colonoscopic techniques.
  3. Improvements in treatment options.
75
Q

Differential diagnosis for bowel cancers.

A
  • Anorectal pathology:
  • Haemorrhoids, anal fissure, anal prolapse
  • Colonic pathology:
  • Diverticular disease, IBD, ischaemic colitis
  • Small intestine and stomach pathology:
  • Massive upper GI bleed - haematochezia
  • Meckel’s diverticulum

9. GI system (15 decks)

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