Patho - GI Neoplasia Flashcards
1
Q
What are the screening methods of detection for GI neoplasia?
A
- hemoccult
- InSure FIT test
- cologuard
- colonoscopy (definitive)
2
Q
Hemoccult sensitivity
A
- sensitivity as low as 4.9% if using a single card
- sensitivity increases if multiple samples used on 3 cards
- does not distinguish b/w human and animal hgb
3
Q
Where does a hemoccult detect blood from?
A
- the entire length of GI tract
- can detect from the esophagus
4
Q
reasons for doing a hemoccult
A
- colon cancer screening
- detect bleeding from peptic ulcer dz
5
Q
When would you do a hemoccult?
A
- complete PE
- abdominal/pelvic complaint
6
Q
What would cause a false positive in a hemoccult?
A
- dietary animal blood in meat (avoid 3 days prior)
- hemorrhoids
- menstruation
- vit. C and other antioxidants that interfere w/ peroxidase rxn
- intermittent bleeding
- sampling error
7
Q
hemoccult cost
A
about $14
8
Q
what does FIT stand for?
A
fecal immunochemical test
9
Q
FIT test sensitivity and specificity
A
- 78% sensitive for colorectal CA (33% more than guaiac/hemoccult)
- 98% specific
10
Q
How does an immunochemical test (FIT) work?
A
- involves monoclonal antibody coated chromatography test strip
- specific to the globin portion of human** hgb
- can be done at home on 2 different stool test
- uses a brush to skim the surface of the stool
11
Q
Why is a FIT test only specific to colonic bleeds?
A
hgb won’t survive the path through the GI tract if it comes from higher up
12
Q
what is the false positive rate for colon CA w/ a FIT test?
A
2%
13
Q
Cologuard sensitivity and specificity
A
- 92% sensitive
- 87% specific
14
Q
how does the cologuard test work?
A
- DNA testing
- stool is lab tested for mutated DNA
- looks for DNA mutations that are suggestive of a tumor
- doesn’t telly you what or where - just that there is mutated DNA present
15
Q
Research comparing FIT and DNA testing
A
- sensitivity for detecting colorectal CA was 92.3% with DNA testing and 73.8% with FIT
- similar comparison for detecting advanced precancerous lesions
- DNA testing also was better at detecting polyps
- FIT had better specificity
16
Q
What are the symptoms used as methods of detection?
A
- pain
- mass effect
- achalasia
- dysphagia
- painless jaundice
- weight loss
- change in character of stool
- hematochezia
- obstruction
-can be incidental finding
17
Q
When does visceral pain arise?
A
- when there is ischemia
- or when there is a tumor pressing against a capsule
18
Q
Why is painless** jaundice an important symptom?
A
- painless jaundice is pancreatic cancer until proven other wise
- painful** jaundice is likely caused by something like a stone
19
Q
What is the #1 cause of bowel obstruction in someone who has, and has not, had abdominal surgery?
A
- someone who HAS: adhesions
- has NOT: neoplasia
20
Q
What are the modalities for detection?
A
- KUB (won’t really use)
- CT - contrast
- Ultrasound
21
Q
once a tumor is detected, what are the modalities used?
A
- PET scan (initially and serially)
- Bone scan
- Tumor board for best option
22
Q
if pt is too sick to get a colonoscopy, what can be done?
A
- barium enema (or swallow) xray
- would show as a filling defect
23
Q
What are the two cellular origins of neoplasia in the GI tract?
A
- Squamous: top and bottom of the tract, where mucosa meets the skin (i.e oral mucosa)
- Adenomatous: arising from glandular cells, GI epi
24
Q
What is the first step when considering treatment options?
A
biopsy and staging
25
TNM staging
- T: size or direct extent of primary tumor
- N: degree of spread to regional lymph nodes
- M: presence of mets
26
What are the following treatment options once the tumor has been biopsied and staged?
- debulking (just a delay, not cure)
- chemo/radiation therapy
- surgery
- palliative care
27
when is targeted therapy used?
-usually when everything else has failed
28
targeted therapy examples
- drugs that target blood vessel growth (sorafenib, bevacizumab, paxopanib, regorafenif)
- drugs that target epidermal growth factor receptor (cetuximab, panitumumab)
- mitogen-activated protein kinase enzyme inhibitors (trametinib)
29
What is the cellular origin of cancer of the oral cavity?
- 90% are of squamous in origin (from the lip to the hypopharynx)
- could be adeno (salivary), lymphoid (always an option) or melanoma
30
what are the precancerous forms in the oral cavity?
- leukoplakia
- erythroplakia (worse)
- usually on lateral margins of the tongue - all non keratinized stratified squamous epi
31
What is the downfall of most oral cancers located on the posterior tongue or hypopharynx?
they are often only detected after mets to neck nodes
32
risk factors for oral cavity cancer
- male (2X)
- > 40
- tobacco/ETOH
- sun exposure (lower lip)
33
prognosis of oral cavity cancer
5 yr survival rate: 57%
34
What is the relationship of oral cavity cancer with HPV?
- most squamou cell carcinomas of the oral cavity are induced into caner by HPV
- if the tumor is HPV positive, there is a better outcome
- in US, mostly HPV derived
35
Treatment options of oral cavity cancer
- after the routine biopsy, CT, PET:
- surgery
- PEG tube
- radiation
- cooling
36
what are the side effects of radiation in oral cavity cancer?
- loss of taste
- loss of salivation (xerostomia)
- can take amifostine prophylactically to help prevent damaging salivary glands
37
Why do some people have molar extracted before beginning oral cancer treatments?
-the radiation damages the gingiva and causes pts to lose teeth
38
esophageal cancer cellular origins
- Upper 2/3: squamous (somatic control)
| - Bottom 1/3: adeno (autonomic control)
39
Which type of esophageal cancer is most common?
- in US: adeno
| - worldwide: squamous
40
outcome of esophageal cancer
overall 5 yr survival: 18%
41
Tx options for esophageal cancer
- surgery, radiation/chemo, palliative
- dilation (increasing diameter of esophagus b/c has a tendency to scar down)
- stent placement
42
risk factors for esophageal cancer
- tabacco/ETOH**
- obesity
- GERD
- Barrett's esophagus
- esophageal web
- achalasia
- tylosis: excess skin on palms/soles
43
What is significant about GERD as a risk factor to esophageal cancer?
- don't take heartburn lightly
- if it doesn't respond to prilosec, be very cautious
- all long term reflux needs to be worked up
- irritant to lower esophagus just like tobacco/ETOH
44
signs and symptoms side note
all of the signs and symptoms are intuitive and we won't be asked specific questions about them - review to have general understanding
45
cellular origins of gastric cancer
- 95% are adenocarinoma
- others include:
- lymphoma
- leiomyomas
- squamous cell
- carcinoid
46
What is a carcinoid tumor?
- a specific tumor type that produces neuroendocrine secretory products (like serotonin)
- mostly found in GI tract and lungs
47
carcinoid syndrome
- facial flushing
- facial purpleish spider viens on nose/face
- tachy
- diarrhea
- asthma-like SOB
48
Why do carcinoid tumors in the lungs cause carcinoid syndrome but ones in the GI tract do not?
the liver metabolizes he secretory products if they come from the GI tracts
49
outcome of gastric cancer
5 yr survival: 29%
50
diagnosis of gastric cancer
- CBC (30% are anemic)
- hemoccult
- EGD
- CMP (for liver enzymes)
- CEA (carcinoembryonic ag)
51
CEA testing in gastric cancer
- it is an antigen that will be elevated in about 50% of cases
- also used for serial testing after surgery
- CA 19-9 is another antigen used
52
how is gastric cancer staged?
-endoscopic US
53
How common is gastric cancer?
15th most common malignancy
54
What is the relationship between the area in the stomach of the cancer and outcome?
-arising near the pylorus has better outcome than in cardia -probably b/c of better detection
55
tx of gastric cancer
- surgery: partial/total gastrectomy, esophagogastrectomy
| - chemo/radiation
56
risk factors for gastric cancer
-diet low in fruits/veggies
-fam hx
-infection by h. pylori
hx of stomach polyp > 2cm
-chronic atrophic gastritis
-pernicious anemia
-smoke
57
sister mary joseph's nodule
a nodule in the umbilicus that is often associated w/ advanced malignancy
58
common cancer types of the liver, GB, and biliary tract
- primary liver CA: hepatocellular carcinoma
| - biliary tract: cholangiocarcinoma
59
releationship b/w hepatocellular cancer and hepatitis
- 2% d/t hepatitis
| - up to 50% of all cancers in undeveloped countried d/t hepatitis
60
tx of cancer of the liver, GB, and biliary tract
- resection
| - Nexavar if unresectable (increases overall survival)
61
5 yr survival of cancer of the liver, GB, and biliary tract
- early stage w/ transplantation: 60-70%
- small resectable w/o cirrhosis: 50%
- localized stages: 30%
- regional mets: 10%
- distant mets: 3%
62
liver cancer screening
- US
- LFTs
- serial testing (AFP) q. 6 mo
63
benign hepatic tumors
- hemangioma
- hepatic adenoma
- focal nodular hyperplasia
- cysts
- lipoma
- fibroma
- leiomyoma
64
what is significant of cysts of liver or pancreas?
you might think it is just a benign cyst, but it could be a cyst d/t necrotic tissue surrounding cancerous cells
65
risk factors stats for hepatic CA
- men (behavior)
- asian americans and pacific islanders
- hep C (<5% progress to CA)
- hep B - MC cause worldwide
66
risk factors for HCCA
- cirrhosis
- hep B and C
- fatty liver
- obesity
- hemochromatosis
- environmental: vinyl chloride, arsenic
- anabolic steroid** board
67
sites of cholangiocarcinoma
- perihilar: 50% (where right and left hepatic ducts join, aka Klatskin tumors)
- distal: 30%
- intrahepatic: 10%
68
cellular types of cholangiocarcinoma
- almost all are adenocarcinoma
- few are lymphomas, sarcomas, and small cell
- benign: hamartomas and adenomas
69
what population is cholangiocarcinoma most common in?
-hispanic americans and native americans
70
Modalities for cholangiocarcinoma
- CT
| - ERCP (endoscopic retrograde cholangiopancreatography
71
risk factors for cholangiocarcinoma
- family hx
- hep B and C if intrahepatic
- cirrhosis - ETOH
- inflammatory bowel dz
- long standing inflammation of the duct system: primary sclerosing cholangitis, duct stones, choledochal cysts
- obesity
72
outcome of cholangiocarcinoma
if untreated: 50% at 1 yr, 20% at 2 yrs and 10% at 3 yrs
73
what are the 5 types of cancer of the small intestine?
- adenocarcinoma
- sarcoma
- lymphoma
- carcinoid
- gastrointestinal stromal tumor (GIST)
74
adenocarcinoma of the SI
- mucus secreting cells of the epithelial lining
| - usually of the duodenum and jejunum
75
sarcoma of the SI
- muscularis layer
| - usually in ileum
76
lymphoma of the SI
-usually non-Hodgkin's
77
carcinoid tumor of the SI
usually ileum
78
GIST of SI
rare, soft tissue sarcome
79
What is a specific cancer of the small bowel?
- gastrinoma
| - gastrin secreting tumor from duodenum/pancreas/stomach
80
what does a gastrinoma cause?
Zollinger-Ellison syndrome
81
Zollinger-Ellison syndrome
- characterized by ulcerations in stomach/duodenum/pancreas
| - pancreas has greater malignant potential
82
risk factors for small bowel cancers
- Crohn's dz*** not ulcerative colitis (boards)
- diet: high fat, smoke/cured meats
- familial adenomatous polyposis
- Peutz-Jeghers - inherited polyposis
- celiac dz (true dz, not gluten intolerance)
83
What is a whipple procedure?
- last option for surgical correction
- removes the head of pancreas, duodenum, GB, and bile duct
- can be curative if all CA was removed, but terrible quality of life after
84
What is the only risk factor for tumors of the appendix?
age
85
possible types of appendix tumors
- colonic type adenocarcinoma - only about 10%
- lymphoma
- carcinoid
- mucinous cystadenocarcinoma
- signet ring cell adenocarcinoma - aggressive
- goblet cell adenoma
- paraganglioma
86
prognosis of appendix tumors
- less than 3 cm, not spread: 5 yr survival close to 100%
- less than 3 cm and spread to regional nodes: 78%
- larger than 3 cm, not spread: 78%
- if spread to other parts of body: 32%
87
where do most pancreatic cancers arise?
-within the duct of the exocrine pancreas
= adenocarcinoma (95%)
-about 5% arise from neuroendrocrine tumor from islets
88
prognosis of pancreatic cancer
- w/ mets: 3-6mos: highest mortality of all CAs
- 1 yr: 26%
- 5 yr: 8% (generous)
- 3rd leading cause of cancer-related deaths in US
89
What are the types of neuroendocrine tumors?
- gastrinomas - 1/2 are CA
- insulinomas - most benign; dont call everything reactive hypoglycemia
- glucagonomas: most CA
- somatostatinomas: most CA
- VIPomas: most CA
- PPomas: most CA
90
what are the risk factors for pancreatic CA
- African american
- excess body weight
- chronic pancreatitis
- DM
- fam hx of genetic syndromes: BRCA2 mutation, Lynch, FAMMM
- personal or fam hx of pancreatic CA
- smoking
91
tx option for pancreatic CA
- surgery - only 20% of the time
- radiation
- chemo
- targeted therapy
92
key consideration for pancreatic CA
- always keep this in the back of your mind
- chronic GI compliant, vague abdomen discomfort w/ no relief by PPIs or middle aged woman quickly losing 20 pounds no diet = WORK UP
93
how do most colon cancers begin?
non-cancerous polyps
94
when should colon CA screening begin?
- 50
| - 40 if high risk
95
what are the different types of polyps
- adenomatous: MC
- tubular: <1cm
- tubulovillus adenoma
- villous: increased incidence of CA
- hyperplastic: benign
96
survival stats of colon and rectal CA
- similar
| - stage 1 87-92%
97
anal cancer cell types
- most are squamous
| - some adenocarcinoma (if higher up)
98
risk factors for anal CA
- HPV (HPV-16 specifically)
- anal warts
- HIV
- multiple partners
- smoking
- more common in women and african american men
