Intrabdominal Cancer Flashcards
What are the main variants of gastric cancer?
Intestinal type with gland formation and diffuse type with intercellular adhesion molecules and no gland formation.
What is the most common subtype of gastric cancer?
Gastric adenocarcinoma with lower socioeconomic groups, Japan, CHhile, Costa Rica and Easten Europe and those with multi focal mucosal atrophy
Which regions have higher occurrences of gastric adenocarcinoma?
Japan, Chile, Costa Rica, Eastern Europe, and lower socioeconomic groups.
What are the major risk factors for gastric cancer?
- H. pylori infection
- Genetic condition HNPCC and FAP
*Pernicious anaemia
*Blood group A - Epstein Barr virus infections
- Obesity
- Contaminated water
- GERD
- Alcohol intake
- Consumption of smoked food containing nitrosamines
- Chronic gastritis
- Occupations involving rubber manufacturing, tin mining, and coal exposure.
What protective factors are associated with gastric cancer?
High fruit and vegetable intake.
What is the majority site of gastric cancer occurrence?
The antrum of the stomach.
What are common clinical presentations of gastric cancer?
- Abdominal pain
- Early satiety
- Weight loss
- Fatigue
- Nausea and vomiting
- Dyspepsia
- Dysphagia.
Which lymph nodes are commonly affected by gastric cancer?
- Virchow’s node (left supraclavicular)
- Sister Mary Joseph node (periumbilical)
- Irish node (left axillary).
What are the common sites of metastasis in gastric cancer?
Metastasis includes Blum shelf with metastasis to rectourine pouch
Kruskenberg tumour with metastasis to ovaries which occurs bilaterally
What are the paraneoplastic manifestations of gastric cancer?
Acanthosis nigricans, Trousseau syndrome and, dermatological diffuse seborrheic keratosis and microangiopathic haemolytic anaemia.Metastasis to the lungs can cause pleural effusion and dyspnoea and crackles on auscultation.
What are the investigations for gastric cancer?
Upper endoscopy with biopsy which may show signet cells, a large vacuole of mucin which displaces the nucleus to one side. Higher numbers of signet ring cells are associated with a worse prognosis
CT scan of chest abdomen and pelvis to assess for metastatic disease
Endoscopic ultrasound is ideal for early stage cancers
What is the TNM staging system for gastric cancer?
- T1a: Tumor within the inner layers (mucosa)
- T1b: Tumor through mucosa into submucosa
- T2: Tumor into muscle layer
- T3: Tumor into outer lining
- T4a: Tumor through outer lining
- T4b: Tumor into nearby organs.
What is the first-line treatment for early-stage gastric cancer?
Surgical resection. And endoscopic mucosa resection
How should tumours greater than T2 be managed?
T2 without any evidence of nodal involvement should undergo perioperative chemotherapy followed by surgery.
What is a common complication of gastric cancer treatment?
Dumping syndrome, where rapid gastric emptying causes fluctuations in blood sugar.
What are the key characteristics of gastric lymphomas?
Typically diffuse large B cell lymphoma, requires combined chemotherapy and radiotherapy.
What are the features of gastric lymphomas?
It has similar presentation to gastric cancer, but more prominent fever and night sweats.
How is gastric lymphoma treated?
Treatment of H.pylroi may cause complete remission of MALT lymphoma but for non-MALT, monoclonal antibodies against CD20 is ideal such as rituximab.
What is the most common type of pancreatic cancer?
Adenocarcinoma of the pancreatic duct cells. Majority arise from the pancreatic head, with one third arising from the body and tail of the pancreas. Genetic mutations associated with this is KRAS2 and CDKN2 in majority.
What are common risk factors for pancreatic cancer?
- Smoking
- Age over 55
- Diabetes
- Obesity
- Chronic pancreatitis
- Cirrhosis
- Helicobacter pylori infection
- Chemical exposure in certain industries.
What is a common clinical presentation of pancreatic cancer?
- Painless jaundice from obstruction of common bile duct
- Weight loss
- Abdominal pain.
- There may be weakness, pruritis from bile salts in the skin, dark urine.
*There may be new onset diabetes and Courvoisier sign, with painless jaundice and right upper quadrant mass as chronically inflamed gall-bladder is less likely to dilate, whic indicates pancreatic or biliary cancer.
*There may be signs of malabsorption like steatorrhoea and reccurent thrombophlebitis. Icauses obstructive.
What is the significance of the ‘double duct sign’ in pancreatic cancer?
Dilatation of both the common bile duct and pancreatic duct.
What are the diagnostic features of pancreatic cancers?
LFTs indicating cholestasis with raised ALP/GGT and multi detector computed tomography (MDCT) to image the pancreas with phased imaging based on the time after CT injection.
What does ERCP involve?
Endoscopic retrograde cholangiopancreatography (ERCP)is a test in which an endoscope injects a contrast dye into the biliary duct and pancreatic duct. The level of biliary or pancreatic obstruction can be delineated
What is considered an unresectable tumour in pancreatic cancer?
Unresectable tumours include metastatic disease in liver, peritoneum, omentum and extra-regional lymph nodes and vascular involvement.
What is the treatment of an unresectable tumour in pancreatic cancer?
Treatment is typically with neoadjuvant therapy with chemotherapy with 5-fluoruracil and gemcitabine and radiotherapy prior to surgical resection, as theoretically tissue will be better oxygenated and patient will be more fit to complete chemotherapy. Surgical options include Whipple
What are the stages of pancreatic cancer?
- Stage I: Tumor in pancreas
*stage II: tumour infiltrates bile duct and nearby structures - Stage III: Positive lymph nodes
- Stage IVA: Metastases to nearby organs
- Stage IVB: Metastasis to distant organs.
What determines inoperability of pancreatic cancer?
Inoperability is determined by liver metastases, encasing of superior mesenteric artery, distal lymph node metastases and peritoneal implant. There is a poor prognosis for pancreatic adenocarcionoma with a. 5 year survival rate of 20%.
What are the complications of pancreatic surgery?
Complications of pancreatic surgery is pancreatic fistulas, delayed gastric emptying, anastomotic leaks, bleeding, and infection.
How are unresectable pancreatic tumours managed?
ERCP with biliary stunting is performed to relieve symptoms of obstructive jauntdice.
What are the common sites of metastasis in pancreatic cancer?
Common sites of metastasis is the liver, peritoneum, lungs and bones
What is involved in the Whipple procedure?
Removal of the head of the pancreas, gall bladder, bile duct, and first part of the duodenum.
What are the risks with the Whipple’s procedure?
Whipple’s procedure may cause peptic ulcer disease and dumping syndrome, where there is rapid gastric emptying causing nausea, abdominal cramping sudden blood sugar changes
What are common complications of pancreatic surgery?
- Pancreatic fistulas
- Delayed gastric emptying
- Anastomotic leaks
- Bleeding
- Infection.
What are The features of pancreatic cyst tumours?
Pancreatic cyst tumours are typically diagnosed incidentally on abdominal imaging with CT abdomen/pelvis or ultrasound. If symptomatic, presentation is identical to pancreatic cancer. ERCP will show the main pancreatic duct is dilated.They can be divided into:
What is a mucinous cyst neoplasm?
Mucinous cystic neoplasm is the most common type of pancreatic cyst tumour, presenting at 50 years old with a mass/pain occluding at the body/tail of pancreas. There is typically no dilatation
Serous cyst adenoma occurs in the elderly, with mass/pain and afffects head or body of pancreas with CT showing septal and calcification.
What is the only pancreatic cyst tumour with duct dilatation on ERCP?
Intraductal papillary Mucinous tumour occurs in 60-70 year olds and presents as recurrent pancreatitis. It is the only pancreatic cyst tumour showing
What are the pancreati endocinem tumours?
carcinoid
Insulinoma
Glucagonoma
VIPoma
What are the features of an insuinoma?
occurs throughout the pancreas, with equal likelihood of site being head, boy or tail and are typically over 5cm with muscle lesions. Patients will present with symptomatic hypoglycaemia and patients may have higher BMI to delay symptoms of hypoglycaemia.
How is an insulinoma diagnosed?
It is diagnosed with 48 hour fast and 3-6 hourly blood glucose, plasma insulin and C-peptide levels. CT/MRI can localise lesion, and endoscopic ultrasound and angiography. Management is eating small, regular meals,
What is the typical presentation of a glucagonoma?
Migratory necrolytic erythema (red rash with necrosis of epidermis), diabetes mellitus, and weight loss.
There is glycogenolysis a insulin secretion and inhibition of pancreatic and gastric secretion and gut motility.
What is a VIPoma tumour?
Vasoactive intestinal peptides tumours occur in tail of pancreas, characterised by profound watery diarrhoea, dehydration hypokalemia and hypochlorhydria. Diagnosis is based on raised serum VIP level and over 3 litres of diarrhoea a day. Management is urgent fluid resuscitation and electrolyte supplementation.
What are the risk factors for hepatocellular caricnoma?
Hepatocellular caricnoma is the 5th most common cancer and has a low survival rate. Risk factors include:
viral hepatitis B and C
Alcoholic liver disease
Fatty liver disease
How does cirrhosis present?
Cirrhosis can present with worsening jaundice, pruritus, hepatic encephalopathy, ascites, palpable mass in the upper abdomen, fever, malaise, weight loss, early satiety, abdominal distension, and cachexia and hepatomegaly where there is a craggy liver edge on examination.
There may be variceal bleeding causing haematoemesis, diarrhoea, and there may be hypoglycaemia due to inability to breakdown glycogen stores and erythrocytosis due to excess.
Abdominal pain is the commonest presentation for HCC.
What is the most common cause of hepatocellular carcinoma worldwide?
Fatty liver disease.
What is a marker for hepatocellular carcinoma?
Serum alpha-feto protein produced by the foetal yolk sac and liver, where elevated levels causes advanced hepatocellular carcinoma. It may be elevated in patients with chronic hepatitis, cirrhosis pregnancy and germ/non-germ line tumours
des-gamma-carboxyprothrombin (DCP) indicate portal vein invasion and itnrahepatic metastasis
How does ultrasound appear with fatty liver disease?
It may appear hyperechoic/light grey with fat infiltration
How does fibrosis appear on imaging?
It can appear as hypoechoic/dark grey with fibrosis
What diagnostic method should be avoided in hepatocellular carcinoma?
Liver biopsy is not reccomended for hepatocellular caricnoma due to risk of tumour seeding and bleeding and may not be possible for cholangiocarcinoma .
What is the treatment of hepatocellular carcinoma?
Treatment is surgical resection including liver transplantation, based on the Milan criteria being a single nodule less than or equal to 5cm and 3 or less nodules, with adjuvant therapy until patient receives transplant.
Tumour ablation for early stage HCC with cryotherapy and radiofrequency ablation
- Transarterial chemoembolisation therapies includes intrarterial infusion of cytotoxic agents and embolising the feeding artery of the tumour but is contraindicated for decompensated cirrhosis
What are the chemotherapeutic agents for hepatocellular carcinoma?
Systemic chemotherapy using sorafenib
Lenvatinib, a kinase inhibitor
What is the ideal imaging modality for focal hepatic lesions less than 2cm?
Focal lesions less than 2cm may be difficult to pick up on liver ultrasound, so CT is ideal with contrast
What is cholangiocarcinoma?
Cholangiocarcioa is an aggressive malignancy from the biliary epithelium inside and outside the liver biliary canicculi therefore is classified as either intrahepati or extrahepatic. This neoplasm is difficult to diagnose because obtaining a tissue sample for confirmation is not always possible. Unfortunately, cholangiocarcinoma is often locally invasive or metastatic by the time it is detected.
What is the pathophysiology of cholangiocarcinoma?
It arises from chronic inflammation of the liver/ducts with perihilar cholangiocaricnomam arising from the left or right hepatic ducts. Tumors distal to the biliary confluence are distal cholangiocarcinoma. Intrahepatic cholangiocarcinoma arises from the biliary epithelium proximal to the segmental bile ducts. They can be further divided into small duct from the liver periphery lined by cuboidal cholangiocytes and form small tubular glands without mucin production. Large duct occurs close to liver hilum, arising from biliary glands and mucin production is common. They are more likely to be infiltrating.
What is a key marker for cholangiocarcinoma?
Carbohydrate antigen 19-9 (CA 19-9) for disease severity
What is the cause of cholangiocarcinoma?
*Infection with parasites like liver fluke infestation from consumption of undercooked fish and parasite-induced chronic biliary inflammation
*Primary sclerosing cholangitis: with 400x increased risk, especially with co-morbidity of IBD
*Biliary tree calculi
*Cystic biliary lesions such as choledochal cysts and biliary mucinous cystic neoplasms
*Intraductal papillary biliary mucinous neoplasm
* fatty liver disease
* HNPCC and cystic fibrosis
* Haemochromatosis
What are common sites for metastasis in liver cancer?
- Lung
- Intracranial lymph nodes
- Bone
- Adrenal glands.
What is the typical imaging used for diagnosing hepatocellular carcinoma?
Ultrasound, CT, or MRI.
What is the treatment approach for early-stage hepatocellular carcinoma?
Surgical resection or liver transplantation based on Milan criteria.
What is the definition of cholangiocarcinoma?
Progressive autoimmune cholestasis liver disease with a 400x increased risk, especially with co-morbidity of IBD
What are some common types of cystic biliary lesions?
Cystic biliary lesions include:
* Choledochal cysts
* Biliary mucinous cystic neoplasms
What are the aetiological factors for cholangiocarcinoma?
Aetiology includes:
* Chronic infection with Hep B
* Haemochromatosis
* Fatty liver disease
* Liver cirrhosis
* Genetic predisposition with HNPP and cystic fibrosis
What is the primary treatment for early-stage cholangiocarcinoma?
Resection of early disease
What is the purpose of biliary drainage with ERCP?
To prevent liver atrophy and impaired regeneration due to biliary obstruction
What is the treatment of cholangiocarcinoma?
biliary drainage with ERCP
Volumetric liver analysis
Transarterial cehmoembolisation
What is volumetric liver analysis used for?
To predict future remnant liver volume
What is transarterial chemoembolization?
A procedure using doxorubicin to embolize the artery supplying the tumor
What is the management for intrahepatic cholangiocarcinoma?
Includes portal lymphadenectomy
How is perihilar cholangiocarcinoma primarily managed?
By resection with portal lymphadenectomy
What is MALToma?
A marginal zone non-Hodgkin’s B cell lymphoma typically affecting older patients in their 60s
What are common extranodal sites affected by MALToma?
Extranodal manifestations involve:
* Stomach
* Intestine
* Lungs
* Thyroid
* Skin
* Salivary glands
What is the most commonly affected site for gastric MALToma?
The stomach
What infection is strongly associated with gastric MALToma?
Helicobacter pylori infection
What chromosomal translocations are linked to gastric MALToma?
Chromosomal translocations include:
* 11 and 18
* 14 and 18
What are the clinical presentations of gastric MALToma?
Clinical presentations include:
* Abdominal pain
* Nausea
* Vomiting
* Anaemia
* Gastroesophageal reflux disease
* Dyspepsia
* Occult GI bleeding
What symptoms may intestinal MALToma cause?
Intermittent diarrhea, abdominal pain, and malabsorption
What are risk factors for developing MALToma?
Risk factors include:
* Sjogren’s syndrome (salivary gland MALToma)
* Hashimoto’s thyroiditis (thyroid MALToma)
What chronic infections are linked to specific types of MALToma?
Chronic inflammation linked to:
* Borrelia burgdorferi - cutaneous MALToma
* Helicobacter pylori - stomach MALToma
* Hepatitis C - splenic MALToma
* Epstein-Barr virus - splenic MALToma
* Chlamydia - ocular MALToma
How is MALToma commonly caused at the genetic level?
By translocation of chromosome 14 and 18
What is the method for diagnosing MALToma?
Diagnosis is through excisional/core needle biopsy showing malignant cells in the margin, immunohistochemical stains, and flow cytometry showing CD19+ and CD20+
What additional laboratory findings are associated with MALToma?
Increased LDH and B2 microglobulin
What is required for diagnosing Helicobacter pylori in gastric MALToma?
Stool sample
What staging methods are used for MALToma?
Staging is based on physical exam and CT scan
What diagnostic investigations are used for MALToma?
Investigations include:
* Endoscopy and biopsy of the stomach lining
* Immunohistochemistry to identify B cell lineage
* Staging investigations with CT scan and PET scan
What is the treatment for non-gastric MALToma?
Radiotherapy; chemotherapy is considered for cases with unacceptable toxicity
What is the first-line treatment for Helicobacter pylori?
Triple therapy with PPI, clarithromycin, amoxicillin, and metronidazole
What is the second-line treatment for Helicobacter pylori?
Quadruple therapy with bismuth, tetracycline, metronidazole, and PPI
