GI/GEN - Cancers Flashcards
Pancreatic Cancer
Pathophysiology
Clinical Features
Investigations/Imaging
Endocrine Tumours of the Pancreas
1.) Pathophysiology
- most common type is ductal carcinoma (90%)
- metastases common at diagnosis: spleen, transverse colon, adrenal glands, liver, lungs, peritoneum
- risk factors: smoking, chronic pancreatitis, FH, DM (late onset)
2.) Clinical Features - tumours of head of the pancreas
- painless obstructive jaundice (compresses CBD)
- weight loss (also due to exocrine dysfunction)
- abdo pain (non-specific), abdominal mass
- Courvoisier’s Law: jaundice + palpable gallbladder suggests malignancy of pancreas of biliary tree
- others: acute pancreatitis, thrombophlebitis
3.) Investigations
- bloods: FBC, LFTs (obstructive jaundice), CA19-9
- double duct sign on all imaging (common bile and pancreatic duct)
- abdominal USS: mass or dilated biliary tree
- staging CT: once cancer has been diagnosed
- endoscopic US (EUS): to guide aspiration biopsy if diagnosis is unclear, ECRP also for biopsy
4.) Endocrine Tumours of the Pancreas - may be functional (secretory) or non-functional
- gastrinoma (G-cells) –> Zollinger-Ellison syndrome
- glucagon-oma (a-cells) –> hyperglycaemia, DM
- insulin-oma (ß-cells) –> hypoglycaemia symptoms
- somatostatin-oma (D-cells) –> inhibits GH, TSH, PRL, gastrin –> DM, gallstones, weight loss, achlorhydria
Management of Pancreatic Cancer
Surgical Management
Whipple’s Procedure
Chemotherapy
Palliative Care
1.) Surgical Management - only curative option is radical resection, changes depending on location
- head: Whipple’s (pancreaticoduodenectomy)
- body/tail: distal pancreatectomy
- contraindications: metastases, pancreatic fistula, delayed gastric emptying, pancreatic insufficiency
2.) Whipple’s Procedure
- remove head of the pancreas, antrum of the stomach, common bile duct, 1st and 2nd part of the duodenum
- all share blood supply from gastroduodenal artery
- tail of the pancreas and hepatic duct then attached to the jejunum whilst stomach is anastomosed to jejunum
- allows bile, pancreatic juices, food to enter the gut
3.) Chemotherapy
- adjuvant chemotherapy (usually 5-flourouracil) is usually given after surgery to prevent cancer returning
- in metastatic disease, FOLFIRINOX regime is used (folinic acid, 5-Flourouracil, irinotecan, oxaliplatin
4.) Palliative Care - most can’t have curative surgery
- biliary stent: for obstructive jaundice and pruritus
- chemotherapy: gemcitabine-based regime
- exocrine insufficiency: enzyme replacements
Gastric Cancer
General Information (prognosis, type, risk factors)
Clinical Features
Investigations/Imaging
Complications
1.) General Information
- 5th most common, 2nd highest cause of deaths
- majority from gastric mucosa as adenocarcinoma
- primary tumours: GIST (stromal tumour), SCC, MALT lymphoma, carcinoid tumour, small cell carcinoma
- risk factors: ↑age, male, H.pylori, smoking, FH
2.) Clinical Features - vague and non-specific
- dyspepsia, dysphagia, early satiety, N+V, melena
- weight loss, anorexia, anaemia
- epigastric mass, palpable Virchow node
3.) Investigations/Imaging
- bloods: FBC, LFTs, U+Es,
- OGD (initial): new onset dysphagia or >55 presenting w/ weight loss + upper abdo pain/reflux/dyspepsia
- biopsy: histology, CLO test (H pylori), FISH (Her2)
- staging CT-CAP OR PET-CT: metastatic spread
- staging laparoscopy (peritoneal mets)
- PET scans rarely used (Not PET avid)
4.) Complications
- gastric outlet obstruction, iron deficiency anaemia, perforation, malnutrition
- acanthosis nigricans: paraneoplastic syndrome (mets)
- poor prognosis: 10yr survival rate is 15%
Management of Gastric Cancer
Nutrition
Curative Treatment
Palliative Management
1.) Nutrition - adequate nutrition is essential
- nutritional status assessment by dietician
- many will need an NG or gastrostomy tube
2.) Gastrectomy - curative surgery
- proximal: total gastrectomy, distal (subtotal)
- distal oesophagus —> small bowel (Roux-en-Y reconstruction)
- complications: mortality, ↓QoL, anastomotic leak, dumping syndrome, vitB12 deficiency, re-operation
- endoscopic mucosal resection if early tumour (T1a)
3.) Palliative Management - most patients
- chemotherapy, best supportive care
- stenting: for gastric outlet obstruction
- palliative surgery
Oesophageal Cancer
Squamous Cell Carcinoma (SCC)
Adenocarcinoma
Clinical Features
Investigations/Imaging
Prognosis
1.) Squamous Cell Carcinoma
- mainly affects upper and middle third of oesophagus
- more common in the developing world
- risk factors: smoking, excessive alcohol, chronic achalasia, vitA/iron deficiency
2.) Adenocarcinoma
- mainly affects lower third of the oesophagus
- due to metaplastic epithelium due to Barrett’s oesophagus (stratified squamous –> simple columnar)
- risk factors: age, male, GORD, obesity, high fat intake
3.) Clinical Features
- progressive dysphagia (solids –> liquids)
- weight loss (dysphagia and metastatic disease)
- odynophagia, hoarseness of voice
- supraclavicular lymphadenopathy
- metastatic signs: jaundice, ascites, hepatomegaly
4) Investigations/Imaging
- 2WW OGD (gold): progressive dysphagia or (>55, weight loss, reflux)
- non urgent OGD: other sx e.g. odynophagia
- staging CT and PET-CT for distant metastases
- EUS measures penetration into oesophageal wall
- staging laparoscopy for intra-peritoneal mets
- bronchoscopy for hoarseness or haemoptysis
5.) Prognosis - 5yr survival is 5-10 %
- 46.5% at one year post diagnosis in UK
Management of Oesophageal Cancer
Curative Management
Surgical Techniques
Surgical Complications
Palliative Management
1.) Curative - surgery +/- chemo/radiotherapy
- SCC: definitive chemo-radiotherapy
- adenocarcinoma: neoadjuvant chemo –> resection
- big surgery, can take 6-9 months to recover
2.) Surgical Techniques - oesophagectomy
- remove the tumour, top of stomach, lymph nodes
- stomach made into conduit to replace oesophagus
- early cancers or high grade Barrett’s can just require endoscopic mucosal resection (EMR)
3.) Surgical Complications
- anastomotic leak most common: need CT chest w/ IV contrast
- pneumonia, re-operation, death
- post-op nutrition: feeding jejunostomy often used or patients have to eat 5-6 small meals per day
4.) Palliative Management - majority (70%)
- oesophageal stent for dysphagia
- chemo/radiotherapy to improve symptoms
- nutritional support: thickened fluid, supplements
- gastrostomy tube if dysphagia too severe
Colorectal Cancer
Pathophysiology
Referral Criteria/Clinical Features
Colorectal Cancer Screening
Investigations
1.) Pathophysiology - 3rd most common type of cancer
- locations: rectal (40%), sigmoid (30%), descending (5%), transverse (10%), ascending and caecum (15%)
- types: sporadic (95%), HNPCC (5%), FAP (<1%)
- HNPCC (Lynch syndrome): autosomal dominant, highly aggressive, ↑risk of other cancers (endometrial (main), ovarian)
- FAP: autosomal dominant, mutation of APC gene (TSG) –> adenomatous growth (polyps) –> carcinoma
- other risk factors: ↑age, IBD, low fibre, smoking, alcohol, meat
2.) Referral Criteria - urgent 2WW to colorectal services for a colonoscopy (and gastroscopy for ID-anaemia)
- >40 w/ abdominal pain + unexplained weight loss
- >50 w/ unexplained rectal bleeding
- >60 w/ change in bowel habit OR ID-anaemia
- ‘consider’ 2WW: unexplained mass (abdominal rectal, or anal) or anal ulceration, <50 w/ rectal bleeding + one of: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia
3.) Colorectal Cancer Screening - 60-74 every 2 years
- faecal immunochemistry test (FIT): type of faecal occult blood (FOB) test that detects and quantifies human haemoglobin in a stool sample
- patient is informed if the test is normal or abnormal and is then offered a colonoscopy if needed
4.) Investigations
- bloods: FBC, carcinoembryonic antigen (CEA)
- gold: colonoscopy (w/ biopsy) (if contraindicated: flexible sigmoidoscopy or CT colonography)
- TNM classification: T1 involves submucosa, T2 involves muscularis propria, T3 involves (sub)serosa, T4a is spread through serosa, T4b is other tissues, N1 is spread to 1-3 nodes, N2 is >3nodes, M1 is mets
- staging CT-CAP for mets and other cancers
- rectal cancer: MRI rectum, endo-anal ultrasound
Surgical Management of Colorectal Cancer
Surgical Resection
Surgical Operations
Other Management
1.) Surgical Resection - most common
- can be potentially curative or used palliatively to reduce the tumour size and improve symptoms
- laparoscopic or robotic surgery is preferred
- end-to-end anastomosis OR a stoma is created
2.) Surgical Operations
- 1.) anterior resection: high rectal tumours (>5cm from anus), loop ileostomy to protect anastomosis
- 2.) abdominoperineal (AP) Resection - low rectal tumour (anal involvement), remove distal colon, rectum, and anal sphincters, resulting in a permanent colostomy
- 3.) sigmoid colectomy: sigmoid colon tumours, the IMA is fully dissected out w/ the tumour
- 4.) left hemicolectomy: descending colon tumours, remove left middle colic vessels, left colic vessels
- 5.) right hemicolectomy: caecal or ascending colon extended right hemicolectomy for transverse colon, remove ileocolic, right colic and right branch of the middle colic vessels
3.) Other Management
- adjuvant chemotherapy (5FU and oxaliplatin) for those with risk factors for disease recurrence
- neoadjuvant radiotherapy for rectal cancer
- palliative care: endoluminal stenting or stoma formation for bowel obstruction
