Upper GI Cancer Flashcards
- Gastric cancer - Liver cancer - Pancreas cancer - Cholangiocarcinoma
Epidemiology of Gastric cancer
- 5th most common cancer
- 2nd most common cause of death
Type of gastric cancer
- Adenocarcinoma (90%)
- lymphoid
- connective tissue
- neuroendocrine
RF of gastric cancer
- Non modifiable
- Male
- Age
- FHx
- pernicious anaemia
- Japan, china
- Modifiable
- H.Pylori
- Smoking
- Alcohol
- Salty diet
*
Where would gastric cancers normally appear?
- antrum
What are the Sx of gastric cancer?
* majority present at advanced stage
- dyspepsia
- dysphagia
- wt loss
- anaemia
What signs will you find on cinical examination?
- epigastric mass
- Troisier sign - palpable Virchow’s node(left supraclavicular node)
- Other signs of metastasis
- hepatomegaly
- ascites
- jaundice
- acanthosis nigricans
Differentials for Gastric cancer
- PUD
- GORD
- Pancreatic cancer
What Ix would you order for gastric cancer?
Bedside
- FBC
- LFT
- Clotting
Imaging
- CXR - check for mets
- CT chest abdo pelvis - staging
Special test
- Urgent OGD - primary investigation
What are the NICE guidelines for urgent OGD referral
- new onset dysphagia
- >55 c weight loss
- upper abdominal pain, reflux, dyspepsia
What is the Mx plan for Gastric cancer
Curative tx
- Early Gastric Cancer (EGC) resection
- partial gastrectomy - if distal
- total gastrectomy - if proximal
- Roux-en-Y for both
- Endoscopic Mucosal Resection (EMR)
Palliative
- Chemo
- pyloric stenting
- gasro-jejunostomy
What are the Cx for Gastric cancer
- gastric outlet obstrction
- iron deficiency anaemia
- perforation
- haematemesis, melaena
In liver cancer, which is more common, metastatic or primary?
- Metastatic 90%
- Primary 10%
What is the type of cancer in primary liver cancer?
- Hepatocellular Carcinoma (HCC)
What is the epidemiology of HCC?
- 6th most common cancer
- 3rd cause of cancer death
What are the risk fctors for HCC?
Non modifiable
- Age
- FHx
- Male
Modifiable
- Hepatitis B & C
- Chronic alcohol
- Smoking
- Aflatoxin exposure (toxic fungal metabolite found in cereal and nuts)
What are the ligaments of the liver?
- Right coronary
- Right triangular
- Left coronary
- Left triangular
- Falciform
What are the clinical features of HCC?
* similar to liver cirrhosis
- Fatigue, fever, weight loss
- Ascites, jaundice
- Dull RUQ pain - specific to HCC
On examintaion
- irregular, craggy and tender liver
What are the differentials of HCC?
- Hepatitis
- Cardiac failure
- Benign hepatocellular adenoma
What Ix would you order for HCC?
Bedside
- FBC - low hb
- LFT
- Clotting test - pronlonged
- alpha fetoprotein AFP - raised
Imaging
- USS
- CT - for staging
- MRI
Special test
- Liver biopsy - risk of tumour seeding
How would you diagnose HCC?
- USS >2cm mass
- AFP raised
What staging syste would you use for HCC
Barcelona CLinic Liver Cancer (BCLC)
WHat risk assessment tool you can use for liver cirrhosis and what does it measure?
MELD score
- Creatinine
- bilirubin
- INR
- sodium
- use of dialysis
What does the MELD score predict?
- mortality from cirrhosis
- likelihood of patient tolerating liver transplant
What is the Mx for HCC?
Non surgical
- image guided ablation - for early HCC (BCLC 0)
- transarterial embolisation - for BCLC stage B
Surgical
- Resection
- Transplantation - must satisfy Milan criteria
What is the Milan Criteria?
- 1 lesion smaller than 5cm or 3 lesions smaller than 3cm
- No extrahepatic manifestation
- No vascular infiltration
What cancers commonly metastasise to liver?
- bowel
- breast
- pancreas
- stomach lung
What is cholangiocarcinoma
cancer of biliary system
What is the biliary tree made of?
- R&L hepatic ducts
- Common hepatic duct
- cystic duct
- common bile duct
- pancreatic duct
- hepatopancreatic duct (ampulla of vater)
Where is the most common location of cholangiocarcinoma?
- birufication of R&L hepatic duct (Klatskin tumours)
What cells bring rise to cholangiocarcinoma?
- Cholangiocytes (95%)
- squamous cell carcinoma
- sarcoma (coonective tissue)
- lymphoma
- small cell carcinoma
What are the RF for cholangiocarcinoma?
- Intramural gallbladder wall calcification (porcelain gall bladder)
- Primary sclerosing cholangitis
- UC
- Liver fluke, hepatitis
- CHemicals in rubber and aircraft
- Caroli’s disease
- choledocal cyst
- excess alcohol
- DM
What are the clinical features of cholangiocarcinoma?
*present at late stage
- post hepatic jaundice
- pruritis
- pale stools, dark urine
- other cancer related sx
What will you find on examinatin for cholangiocarcinoma
- jaundice
- cachexia
- Courvoisier’s law
What is corvoisier’s law?
- palpable enlarged gallbladder + jaundice = suspect malignancy of biliary tree as gall stone is unlikely
What are the differentials for cholangiocarcinoma
*think things that cause post hepatic jaundice
- primary sclerosing cholangitis
- biliary cirrhosis
- pancreatic tumours
- beningn biliary tumours
- bile duct strictures
- gall stones
What Ix would you order for cholangiocarcinoma
Bedside
- Bloods
- LFT - elevated bilirubin, ALP, yGT
- CEA & CA19-9 - tumour markers
Imaging
- USS
- MRCP
- ERCP
- CT - staging
What are the Mx options for cholangiocarcinoma?
Surgical
- Comlete resection
- partial hepatetctomy + reconstruction of biliary tree - Klatskin tumour
- Whipple’s procedure - pancreaticoduodenectomy - for distal common duct tumours
Palliative
- ERCP stenting
- Bypass
- raidotherapy
What is Whipple’s procedure?
- Removal of
- head of pancrease
- duodenum
- gall bladder
- bile duct
What are the Cx of cholangiocarcinoma
- Biliary tract sepsis
- Secondary biliary cirrhosis
What are the types of pancreatic cancer?
Where do they typically appear?
- ductal adenocarcinoma (90%)
- exocrine tumours - pancreatic cystic carcinoma
- endocrine tumours - islet cells
- Head (60%)
- body (25%)
- tail (15%)
What is the epidemiology of pancreatic cancer?
- 4th most common cause of cancer death
Whar are the RF for pancreatic cancer?
- Non modifiable
- FHx
- Modifiable
- Chronc pancreatitis
- Smoking
- late onset DM >50
How would pancreatic cancer present?
- Obstructive jaundice (90%)
- painless
- Weight loss - due to exocrine dysfunction
- Abdominal pain - invasion of celiac plexus
- Acute pancreatitis
- Thrombophlebitis sign
- Red, swollen skin around effected site
*
- Red, swollen skin around effected site
What will you find on Ex on pt with pancreatic cancer?
- Cachexia
- Malnourished
- Jaundice
- Abdominal mass @ epigastric region
- Enlarged gall bladder
- Courvorsier’s law
What is Courvoisier’s law?
- In the presence of jaundice and palpable gallbladder, cholangiocarcinoma or pancreatic cancer should be suspected
What are the differential diagnosis for pancreatic cancer?
- Think about causes of obstructive jaundice
- gall stones
- cholangiocarcinoma
- gall bladder stricture
- Think about causes of epigastric pain
- gallstones
- PUD
- gastric carcinoma
- ACS
What Ix would you order for pancreatic cancer?
Bedside
- Bloods
- Tumour marker: CA 19-9 - high sensitivity and specificity for pancreatic cancer
- LFT: raised bilirubin, ALP, y-GT
- FBC: anaemia
Imaging
- USS: pancreatic mass, dilated biliary tree
- CT abdo
- CT chest-abdo-pelvis: staging
- PET CT-scan
Special test
- Endoscopic ultrasound (EUS)
- ERCP
How would you Mx pancreatic cancer?
Surgical
- Whipple’s procedure - if head of pancreas
- Distal pancreatectomy - if tail of pancreas
Chemotherapy
- Adjuvant with 5 fluorouracil
Palliative care (most patients)
- ERCP biliary stent
- Enzyme replcament
What is the prognosis of pancreatic cancer
- 5 year survical rate <5%
