GI malignancy Flashcards
What are common sites of cancer in the GI system?
- Oesophagus
- Liver
- Stomach
- Pancreas
- Gallbladder
- Large intestine
- Anus
What is the difference between carcinoma and adenocarcinoma?
- Carcinoma is malignancy of cells that make up epithelial lining of skin or tissue lining organs
- Adenocarcinoma is malignancy of glandular cells in epithelial tissue
What is an adenoma?
- Benign tumour formed from glandular structures in epithelial tissues
What presentation is suggestive of oesophageal cancer?
- Severe dysphagia to solids
- Worsening dysphagia to liquids
- Unexplained weight loss
- Mild odynophagia
- Coughing up mucus secretions
What is the histology of oesophageal cancer?
- Most common squamous cell carcinoma worldwide
- Generally affects upper 2/3
- Adenocarcinomas from columnar epithelium can occur in lower 1/3
- Barrett’s oesophagus
What are the red flags for oesophageal cancer?
- Progressive dysphagia
- Anaemia
- Unintentional weight loss
- Anorexia
- Recent onset of progressive symptoms
- Malaena or masses
What are the risk factors for oesophageal cancer?
- Squamous cell carcinoma
- smoking
- alcohol use
- dietary intake e.g. hot beverages - Adenocarcinomas
- obesity
- reflux disease
- Barrett’s oesophagus
What is the prognosis of oesophageal cancer?
- 5% survival at 5 years
What are the investigations for oesophageal cancer?
- FBC to check for anaemia
- Oesophagogastroduodenoscopy (OGD) with biopsy - helps to determine whether benign or cancerous
- CT thorax and abdomen - size of primary, local invasion, metastatic spread
What is the treatment for oesophageal cancer?
- Endoscopic therapies (limited disease)
- Oesphagectomy (removes oesophagus)
- Chemoradiotherapy
What is the histology of gastric cancer?
- Most commonly adenocarcinomas
- Most often found in gastric cardia
- Can get lymphoma, leiomyosarcoma, neuroendocrine tumours
How is gastric cancer classified?
- Location - either cardia gastric cancer or non-cardia gastric cancer
- Lauren classification tells us the type
- Either diffuse or intestinal
- Diffuse occurs more often in young people and has worse prognosis
What are the general risk factors for gastric cancer?
- Age 50-70
- Male
What are the strong risk factors for gastric cancer?
- Pernicious anaemia
- H-Pylori
- N-nitroso compounds
What are the weak risk factors for gastric cancer?
- Family history
- High salt (weakens gastric mucosa and enhances negative effects of N-nitroso compounds)
- Smoking
What is the common clinical presentation of gastric cancer?
- Unexplained weight loss
- Epigastric abdominal pain
- Lymphadenopathy - Virchow’s node (left supraclavicular fossa)
- Dysphagia (if cancer is located around the cardia)
What is the prognosis of gastric cancer?
- 70% 5-year survival for local disease
- Decreases to 5% if there’s metastasis
What are the investigations for gastric cancer?
- Bloods - look for iron deficiency anaemia
- Upper GI endoscopy and biopsy for tissue diagnosis
- CT CAP (chest, abdomen and pelvis) for staging/determining extent of disease
How is gastric cancer managed?
- Endoscopic mucosal resection - treats superficial cancer
-Surgery to remove all or part of the stomach (gastrectomy) - treats localised cancer - If pt not suitable for surgery, then chemoradiation
- Chemotherapy/immunotherapy and supportive care - treats advanced/metastatic cancer
What is the histology of pancreatic cancer?
- Pancreatic ductal adenocarcinoma is main type
- Pancreatic neuroendocrine tumours are rare and originate from pancreatic endocrine cells
- Cancers may be non-functional or may secrete hormones
What are the risk factors for pancreatic cancer?
- Smoking
- Chronic pancreatitis
- Inherited mutations
- Men > women
- Increasing age
Which mutations can lead to pancreatic cancer?
- BRCA1
- BRCA2
- PALB2
- Familial syndromes
What is the clinical presentation of pancreatic cancer?
- Painless jaundice
- Unexplained weight loss
- Abdominal/back pain
- New-onset type 2 diabetes mellitus in an adult over 50 without any obesity-related risk factors
What are the symptoms of pancreatic cancer?
- Indigestion
- Tummy pain or back pain
- Changes to your poo
- Unexplained weight loss/loss of appetite
- Jaundice
What are the investigations for pancreatic cancer?
- Bloods - LFTs if jaundiced, CA 19-9 (tumour marker)
- CT - focused on pancreas can give very high diagnostic accuracy and can assess resectability in 80-90%
- Ultrasound scan - can detect cancer arising in head of pancreas with reasonable accuracy but not in body or tail
What is the management for pancreatic cancer?
- 10-15% are suitable for surgical resections (followed by pancreatic enzyme replacement)
- Only possible cure
- 20% 5 year survival
- Biliary stenting to relieve jaundice
- Chemotherapy and symptom management (if not resectable)
What is the histology of hepatocellular carcinoma?
- Hepatocellular carcinoma
- Primary cancer arising from hepatocytes (usually with a background of cirrhosis)
What are the risk factors for hepatocellular carcinoma?
- Occur in patients with underlying cirrhosis
- Many causes of cirrhosis including alcohol, Hep B&C
What is the clinical presentation of hepatocellular carcinoma?
- Symptoms of underlying liver disease can often mask malignancy e.g. ascites, fatigue
- Acute hepatic decompensation or RUQ pain can be signs of development of HCC
What is the prognosis of hepatocellular carcinoma?
- 5 year survival rate ~50% with complete surgical resection or liver transplantation
- In advanced HCC = median overall survival time with treatment is approx 1 year
What are the investigations for hepatocellular carcinoma?
- Blood tests for LFTs, prothrombin time/INR (checks synthetic function), viral hepatitis panel
- USS - non invasive and good for screening high risk pts
- CT/MRI of abdomen
- Liver biopsy
What is the treatment for hepatocellular carcinoma?
- If suitable then ablation, resection or transplantation
- If not suitable for any of the above then chemotherapy/immunotherapy to slow tumour growth
Outline liver metastases
- Liver is a common site for metastases from many cancer types
- Can be haematological e.g. portal spread from other GI viscera
- Or lymphatic spread
- Or spread via other routes e.g. ovarian is via transcoelomic spread
What is the histology for cholangiocarcinoma (bile duct cancers)?
- Majority are adenocarcinomas
- Can be intra- or extrahepatic
What are the risk factors for cholangiocarcinoma?
- Liver and bile duct diseases - cirrhosis, alcoholic liver disease, non-specific bile duct diseases, gallstones, primary sclerosing cholangitis
- Infections
- High alcohol consumption
- Exposure to certain toxins/medications
What is the clinical presentation of cholangiocarcinoma?
- Painless jaundice
- Pruritis
- Dark urine
- Light colour stool (absence of stercobilin due to biliary obstruction)
What is the prognosis of cholangiocarcinoma?
- Generally poor
- 5 year overall survival rate in patients with metastatic disease is 2%
What is the histology of colorectal cancer?
- Adenocarcinomas which progress from normal epithelium in a classical pattern
What are the risk factors of colorectal cancer?
- High dietary fat
- High red meat consumption
- Low dietary fibre
- Alcohol intake
- History of IBD
- Genetic conditions such as FAP and HNPCC
What is the clinical presentation of colorectal cancer?
- Blood in stool
- Altered bowel habits
- Bowel obstruction
- Perforation
- Symptoms due to hepatic or peritoneal metastases e.g. abdo pain or ascites
What is the prognosis of colorectal cancer?
- Best overall prognosis
- 5-year survival rate ranges from 50% - 95% (non-metastatic)
What are the red flags of colorectal cancer?
- Blood in the stool/rectal bleeding (either fresh red vs mixed in stool vs malaena)
- Change in bowel habit
- Iron deficiency anaemia
- Unexplained weight loss
- Tenesmus
- Mass on rectal examination
How may bowel habits change due to colorectal cancer?
- Inquire more about pain when opening bowels (makes it more likely to be haemorrhoids or fissures)
- If black and tarry stool - more likely to be upper GI
- As we get older, a change in bowel habit is more likely to be due to malignancy
- Can present with constipation as cancer can obstruct bowels
- Can lead to overflow diarrhoea
Outline the features of right-sided colorectal cancer
- Weight loss
- Occult bleeding (not visible to naked eye)
- Less likely to present with bowel obstruction
- Mass in right iliac fossa
-More advanced disease at presentation - Late change in bowel habits
- Fungating (ulceration)
Outline the features of left-sided colorectal cancer
- Weight loss
- Rectal bleeding (bright red and fresh)
- Bowel obstruction more likely
- Mass in left iliac fossa
- Less advanced disease at presentation
- Early change in bowel habit
- Stenosing (strictures/narrowing)
What is the adenocarcinoma sequence?
- Series of genetic and epi-genetic mutations
- Activation of oncogenes
- Inactivation of tumour suppressor genes
- Normal glandular epithelial cells become adenomas
- Adenomas become invasive carcinomas
What are the investigations for colorectal cancer?
- Stool tests e.g. FIT
- Blood tests - FBC for anaemia, CEA
- Colonoscopy and biopsy
- Imaging - CT and MRI
How is colorectal cancer managed?
- Largely dependent on stage
- Surgery with pre or post-operative chemotherapy/ immunotherapy
- Chemotherapy/immunotherapy if not for surgical intervention
What are the barriers to participating in bowel screening?
- Fear and denial around test outcome
- Individual perceived low risk/doesn’t want to know result
- Being male
- Pt believes that test is not applicable to them
- Ethnic minorities
- ## Lower socio-economic group
What are the barriers to participating in bowel screening?
- Fear and denial around test outcome
- Being male
- Pt believes that test is not applicable to them
- Ethnic minorities
- Lower socio-economic group
What is the histology of anal cancer?
- Squamous cell carcinomas
What are the risk factors for anal cancer?
- Strongly associated with HPV infection
- HIV infection
- Engaging in anal-receptive sexual intercourse
- Chronic local inflammation due to IBD and recurrent anal fissures
What is the clinical presentation of anal cancer?
- Perianal pruritis or pain
- Bleeding
- Discharge
- Mass-like sensation
What is the prognosis of anal cancer?
- More than 70% of cases can be cured with chemoradiation
How do we lower the incidence of anal cancer?
- Pap smears in high-risk populations
- Treatment of HIV infection
How is GI cancer staged (TNM staging)?
- TNM staging is standardised system
- T = size of primary tumour
- N = extent of regional lymph node involvement
- M = metastatic spread
- Typically then converted to an overall stage 1, 2, 3 or 4
