Session 8: GI Cancer Flashcards
Give examples of GI cancers (broad)
Oesophageal cancer Gastric cancer Pancreatobiliary cancers Hepatocellular carcinoma Colorectal cancers Anal cancers
What are the red flags of upper GI malignancy?
Dysphagia Epigastric pain Jaundice
What are the red flags of lower GI malignancy?
Bowel obstruction PR bleeding Change in bowel habits
What are the differentials of dysphagia? (Where is the mass found?)
Extraluminal Luminal Intraluminal
Red flags of dysphagia
ALARM Anaemia Loss of weight (unintentional) Anorexia Recent onset of progressive symptoms Masses/Malaena
Subtypes of oesophageal cancer
Oesophageal squamous cell carcinoma Oesophageal adenocarcinoma
What is the most common oesophageal cancer?
Oesophageal squamous cell carcinoma even though there is a decreasing incidence of it and an increasing incidence of oesophageal adenocarcinoma.
Location of oesophageal squamous cell carcinoma.
Upper oesophagus of stratified squamous epithelium
Location of oesophageal adenocarcinoma.
Distal oesophagus and gastroesophageal junction in columnar epithelium
Risk factors of oesophageal squamous cell carcinoma.
Tobacco smoking and alcohol
Risk factors of oesophageal adenocarcinoma.
Obesity Reflux disease Metabolic syndrome
Pathophysiology of oesophageal squamous cell carcinoma.
Chronic mucosal injury caused by tobacco or alcohol.
Pathophysiology of oesophageal adenocarcinoma
Chronic acid reflux leading to Barrett’s oesophagus. Epithelial metaplasia from squamous to columnar epithelium.
Clinical presentation of oesophageal cancer.
Dysphagia Chronic reflux Unintentional weight loss Anorexia Malaise
Diagnosis of oesophageal cancer.
Endoscopy Biopsy Endoscopic US Assessment of T&S CT scan
Treatment of oesophageal cancer.
Surgery resection Chemoradiation Improve QOL
Prognosis of oesophageal cancer.
5% at 5 yrs
Subtypes of gastric cancer.
Diffuse gastric cancer Intestinal gastric cancer
Demography of diffuse gastric cancer.
Young age Signet ring cells Increasing incidence Worse prognosis Can be hereditary
Demography of intestinal gastric cancer.
Older patients History of intestinal metaplasia Decreasing incidence Better prognosis
Where will gastric adenocarcinomas most commonly be found?
In the cardia or antrum
Risk factors of gastric cancer.
Poor food hygiene and most importantly Helicobacter pylori. Food preservatives Smoking High salt diet
Why is there a bad prognosis of gastric cancers?
Because most present late and are often far advanced by then.
Red flags of gastric cancer.
Haematemesis Malaena
Other common symptoms in gastric cancer.
Triad of symptoms: anorexia, anaemia and asthenia. Dysphagia Satiety Epigastric pain Nausea Vomiting GI bleeds Can have a very similar presentation to peptic ulcers.
Diagnosis of gastric cancer.
Oesophagogastroduodenoscopy. Biopsy CT for metastatic disease Screening is common in Japan
Treatment of gastric cancer.
Surgery if it is non-metastatic. This involves removal of stomach, lymph nodes and spleen which can be common in Japan and SK. Chemoradiation if metastatic
Prognosis of gastric cancer.
10% 5y survival 50% after curative surgery
Give examples of other cancers that can occur in the stomach.
Gastric lymphoma Gastrointestial stromal tumours
Red flags of jaundice.
Hepatomegaly Unintentional weight loss Painless Ascites
Give subtypes of pancreatobiliary cancers.
Pancreatic ductal carcinoma Cholangiocarcinoma Pancreatic neuroendocrine tumours
Location of pancreatic ductal carcinoma.
Pancreatic head is most commonly affected. If the body or tail are affected then the symptoms tend to be more vague.
Risk factors of pancreatic ductal carcinoma.
Smoking Chronic pancreatitis BRCA1/2 and PALB2 mutations Peutz-Jeghers Lynch syndrome
Pathophysiology of pancreatic ductal carcinoma.
Accumulation of mutations in the pancreatic duct epithelium. Pancreatic intraepithelial neoplasia leading to invasive adenocarcinoma and fibrotic stroma.
Red flags of pancreatic ductal carcinoma.
Painless jaundice Epigastric pain Unintentional weight loss
Clinical presentation of pancreatic ductal carcinoma.
Painless jaundice Epigastric pain Unintentional weight loss Anorexia Malaise Steatorrhoea Venous thromboembolism
Diagnosis of pancreatic ductal carcinoma.
CT/US/MRI Endoscopic US Biopsy
Treatment of pancreatic ductal carcinoma.
Surgery (very risky) Chemoradiation Improve QOL
Prognosis of pancreatic ductal carcinoma.
<5%
What are cholangiocarcinomas?
Defined as arising from biliary epithelium. They are either intrahepatic or extra hepatic or gallbladder cancers. They are often found incidentally.
Why might cholangiocarcinomas be found on accident?
Because their similar presentation to cholelithiasis and cholecystitis.
Location of cholangiocarcinomas.
Biliary system
Risk factors of cholangiocarcinoma.
Chronic inflammation of biliary system. PSC Cholelithiasis Infection
Clinical presentation of cholangiocarcinomas.
Painless/painful jaundice Epigastric pain Anorexia Unintentional weight loss Malaise Symptoms of cholelithiasis or cholecystitis.
Diagnosis of cholangiocarcinoma.
CT/US/MRI Endoscopic US Biopsy
Treatment of cholangiocarcinoma.
Surgery (very risky) Chemoradiation Improve QOL
Prognosis of cholangiocarcinoma.
<10%
What are pancreatic neuroendocrine tumours?
Tumours of pancreatic parenchyma. They can be non-functional or functional. If they are functional they might affect insulin, glucagon, gastrin or vasoactive intestinal peptide.
Location of pancreatic neuroendocrine tumours.
Pancreas
Pathophysiology of pancreatic neuroendocrine tumours.
Originate from endocrine cells in pancreas
Clinical presentation of pancreatic neuroendocrine tumours.
Symptoms related to its functionality. Hypoglycaemia Hyperglycaemia Zollinger-Ellison syndrome Diarrhoea with electrolyte imbalance
Diagnosis of pancreatic neuroendocrine tumours.
CT/MRI/US Endoscopic US Biopsy Scintigraphy
Treatment of pancreatic neuroendocrine tumours.
Surgery Somatostatin Improve QOL
Prognosis of pancreatic neuroendocrine tumours.
<10%
What is hepatocellular carcinoma?
The most common primary liver cancer.
Are primary liver cancers common?
No
What liver cancers are more common?
Secondary malignancy
How can cancer spread to the liver?
Blood via the portal system Lymphatics Ovaries (transcoelomic) Lungs Breast
Risk factors of hepatocellular carcinoma
Cirrhosis Alcohol Hep B Hep C
Clinical presentation of liver cancer.
Abdominal distention Ascites Fatigue Muscle wasting Anorexia Encephalopathy RUQ pain
Diagnosis of hepatocellular carcinoma.
Can be done without histological confirmation. Cirrhosis Elevated alpha-fetoprotein CT/MRI
Treatment of hepatocellular carcinoma.
Surgery Liver transplant Ablation Chemoradiation
What types of colorectal cancers are most common?
Adenomas They are commonly demonstration by familial adenomatous polyposis
What subtypes of colorectal cancers are there? (anatomical)
Right sided and left sided.
Risk factors of colorectal cancers.
High dietary fat Red meat Low fibre diet Obesity Alcohol IBD Polyposis syndromes such as FAP and HNPCC
Pathophysiology of colorectal cancer.
Arise in polyps. 3 major pathways which may occur - Adenomacarcinoma sequence DNA mismatch repair pathway - Promoter methylation
Red flags of colorectal cancer.
Altered bowel habits Obstructive symptoms Rectal bleeding
Clinical presentation of right-sided colorectal cancer.
Weight loss Anaemia Not common to have bowel obstruction Mass in right iliac fossa Late change in bowel habits Fungating
Clinical presentation of left-sided colorectal cancer.
Weight loss Rectal bleeding Bowel obstruction Mass in left iliac fossa Early change in bowel habits Stenosing Tenesmus
What is usually more advanced upon discovery, L or R.
Right sided.
Why is right sided usually more advanced?
Because symptoms show up later. Caecum and ascending colon is also more distensible.
DXR of bowel obstruction.
Volvulus Diverticular disease Hernias Strictures Pyloric stenosis
DXR of PR bleed
Haemorrhoids Anal fissures Infective gastroenteritis IBD Diverticular disease
DXR of altered bowel habits
Thyroid disease IBD Meds IBS Coeliac disease
General clinical presentation of colorectal cancer.
Altered bowel habits Obstructive symptoms PR bleeding Abdo distention Abdo pain Haematochezia Ascites Anorexia, malaise and unintentional weight loss Tenesmus
Diagnosis of colorectal cancer.
Screening Colonoscopy is golden standard. Sigmoidscopy Barium enema CT/MRI
Treatment of colorectal cancer.
Surgery Laparoscopy Chemoradiation
Prognosis of colorectal cancer.
50-95%
Location of anal cancer.
Anal canal
Risk factors of anal cancer.
HPV infection HIV Anal receptive intercourse Condyloma acuminate
Pathophysiology of anal cancer.
Squamous cell carcinoma. HPV 16&18 inactivation of TSGs TP53 and RB1 by viral proteins E6 and E7 Chronic inflammation by IBD Recurrent anal fissures and fistulas
Clinical presentation of anal cancer.
Perianal pruritus and pain Bleeding Discharge Mass-like sensation Non-healing anal or perianal lesions Anorexia, unintentional weight loss and malaise
Diagnosis of anal cancer
Physical examination CT of chest, abdo and pelvis Inguinal lymph node inspection as it is a common site of early spread.
Treatment of anal cancer
Preventive by vaccination Curable without surgical resection Chemoradiation Permanent colostomy
Prognosis of anal cancer.
70% by chemoradiation
Give examples of changes in bowel habits.
Frequency Consistency Any other associated symptoms
How is large bowel cancer screened for?
Faecal occult Blood sample
Explain how malignancy can arise from a polyp.
Hyperproliferation of the epithelium occurs. This leads to formation of a polyp. The polyp will then undergo dysplasia to form an adenocarcinoma. The adenocarcinoma will then usually start by growing out into the lumen of the bowel. However they can become invasive, this is when they are more prone to metastasise.
Give examples of small bowel cancers.
Stromal Lymphoma Adenocarcinoma Sarcoma Carcinoid tumours
How is staging assessed in GI malignancy?
By Duke’s staging (A-D)
What is the most common site for a gastrointestinal lymphoma?
The stomach
