BRS1 - Valentine > GI cancers > Flashcards

GI cancers Flashcards

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1
Q

What is primary and secondary cancer?

A

Primary - arising directly from the cells in an organ

Secondary- spread from another organ, directl or by other means

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2
Q

What are cancers of the following neuroendocrine cells:

  • enteroendocrine cells
  • Intersititial cells of cajal
A

Enteroendocrine cells- Neuroendocrine Tumours (NETs)

Interstitial cells of Cajal- Gastrointestinal Stromal Tumours (GISTs)

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3
Q

What are the cancers of the following connective tissues of GI tract:

  • smooth muscle
  • Adipose tissue
A

Smooth muscle- Leiomyoma/Leiomyosarcoma

Adipose tissue- Liposarcoma

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4
Q

What are the cancers of the following epithelial cels of the GI tract:

  • Squamous
  • Glandular epithelium
A

Squamous - Squamous cell carcinoma

Glandular epithelium - Adenocarcinoma

N.B. Malignant

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5
Q

What are the 3 demarcations of the Oesophagus

A

Cervical Oesophagus

Middle Oesophagus

Lower Oesophagus

N.B. Left main bronchus is between middle and over oesophagus

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6
Q

Where does squamous cell carcinoma develop in oesophageal cancer? explain it’s features and causes

A

From normal oesophageal squamous epithelium

it affects the upper 2/3 of Oesophagus

it is more common in less develop world

Most related to alcohol as too much alcohol us converted to Acetalaldehyde- Acetylaldehyde pathway

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7
Q

What are the common features of Adenocarcinoma in Oesophageal cancer

A

Develops from metaplastic columnar epithelium

Occurs in lower 1/3 of Oesophagus

it is related to acid reflux

More common in developed world

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8
Q

Describe the progression from GO Reflux to cancer

A

Firstly there’s oesophagitis due to Gastro-oesophageal reflux disease

then Barrett’s Oesophagus (metaplasia) can develop- 5% of GORD population

Dysplasia and high grade dysplasia can form

Then adenocarcinoma can develop

N.B theres’ an increased 30-100 fold risk of cancer if you have GORD

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9
Q

What procedure is used to monitor progression of reflux too cancer

A

Oestro-gastro duodenoscopy (OGD)

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10
Q

Describe the BSG guidelines for Barrett’s surveillance

A

If there’s NO dysplasia - check every 2-3 years

if there’s LOW GRADE dysplasia - check every 6 months

if there’s HIGH GRADE dysplasia - intervention

N.B. Be careful of intervention as it could cause death and you’re not 100% sure the pt will develop cancer

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11
Q

Describe the epidemiology of Oesophageal cancer

A

9th most common cancer

Affects the elderly

In Adenocarcnioma - theres more male affetced than female (10:1)

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12
Q

Describe and exlplain the prognosis of oesophageal cancer, what are the features of it’s late presentatin

A

Late presentation : difficulty swallowing, loss of weight

65% are palliative

HIgh Morbidity and complex surgery

poor 5 year survival - lower than 20%

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13
Q

How do help patients with oesophageal cancer to allow food to pas down Oesophagus. Any complications?

A

Add a stent

sometimes the cancer grows through this

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14
Q

Draw out the management pathway for oesophageal cancer.

If struggling , complete the gaps below

A
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15
Q

What surgical approach is commonly used for oesophagectomy

A

Two- stage Ivor Lewis approach :

a thoracic-abdominal incision is made

add diagram- research this before completing

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16
Q

Describe the epidemiology of Colorectal cancer

A
  • Most common GI cancer in ther West
  • 3rd most common cancer death in men and women
  • Generally affects patients more than 50 yrs old
  • Life time risk is:
    • 10% men
    • 1 in 14 for women
    • Appendicitis - more common in men than women
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17
Q

What are the forms of colorectal cancer- genetics

A

Sporadic - no family history, older population have this form

Familial - there’s family history and relative is a 1st degree one. Pt lower than 50yrs

Hereditary syndrome- family history and there’s specific gene defects . E.g.

  • FAP- Familial adenomatous polyposis
  • HNPCC or Lynch syndrome - Hereditary nonpolyposis colorectal cancer
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18
Q

What’s the histopathology of colorectal cancer

A

Adenocarcinoma

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19
Q

Describe the pathogenesis of colorectal cancer

draw

A
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20
Q

What are the risk factors of colorectal cancer

A

PMHx of - colorectal cancer, ulcerative colitis, adenoma or radiotherapy

Family history - 1st degree relative and relatives with identified genetic predisposition

Diet/environmental- NOT AS HIGH AS A RSIK FACTOR AS THE UPPER 2

  • carcinogenic food
  • smoking
  • obesity and socio-economic status
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21
Q

What does clinical presentation of colorectal cancer depend on

A

The location of the cancer throughout the colon ad rectum

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22
Q

What are the clinical presentations of Caecal and right sided cancer (colo-rectal)

A
  • Iron deficiency anaemia- most common
  • Change in bowel habit (diarrhoea)
  • Distal ileum obstruction- late
  • Palpable mass- late presentation
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23
Q

What are the clinical presentations of left sided and sigmoid carcinoma (Colorectal cancer)

A

PR Bleeding and mucus

Thin stool -late presentation

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24
Q

What are the clinical presentations of rectal carcinoma (colorectal cancer)

A
  • PR bleeding, mucus
  • Tenesmus; cancer presses on anal sphincter
  • Anal, perineal and sacral pain - late presentation
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25
Is bowel obstruction a late or early presentation of colorectal cancer?
Late
26
In colorectal cancer, descirbe the clinical presentation if there's local invasion from colon into other adjacent tissues
they're LATE presentations * Bladder symptoms * Female genetal tract symptoms
27
In colorectal cacner, describe the clinical presentations of when it metastasise (late presentation) to the the following regions: * Liver * Lungs * lymph nodes * Peritoneum in umbilicus
* Liver (**hepatic pain or jaundice**) * Lungs affected- **cough** * regional lymph nodes affected- enlarged * peritoneum in umbilicus - **sister Marie Joseph nodule - in diagram**
28
On physical examination, what are the signs of primary colorectal cancer
* Abdominal mass palpated * Digital rectal exam: less than 12cm dentate and reached by examining finger * Rigid sigmoidoscopy * abdominal tenderness and distension- caused by large bowel obstruction
29
On examination, what are the signs and complications of metastasis of colorectal cancer
Heptomegaly Monophonic wheeze Bone pain
30
What are the investigations needed to be performed on someone with suspected colorectal cancer
* Feacal occult blood * Blood test * Double contrasts barium enema- NOT USED ANYMORE; ONLY HISTORIC INTEREST * Colonoscopy * CT colonoscopy/colonography * MRI pelvis- Rectal cancer * CT of chest/abdo/pelvis
31
Describe the significance of using feacal occult blood test to confirm colorectal cancer? What are the dietary restrictions
Guaiac test (Hameoccult) Based on Pseudoperoxidase activity of Haemattin 98% specificity and 40-80% sensitivity- hence large number of false negative and low false postive results Dietary restrictions: red meat, melons, Vit C and NSAIDs for 3 days before test
32
Describe how blood tests can be used to confirm or monitor colorectal cancer
FBC: anaemia, haemtinics- low ferritin Tumour markets : CEA (Carcinoma embryonic antigen) is used for monitoring. It is NOT A DIAGNOSTIC TOOL
33
Descirbe the features and any advantage/disadvantage of using double barium enema
Doesn't require sedation decreased risk of perforation However, more limited in detecting small lesions all lesions need to be confirmed by colonoscopy and biopsy this is a historic interest only, not routinely used in practice anymore
34
Descirbe the features of colonoscopy in relation to colorectal cancer . What can it allow you to do?
Can visualise lesions less than 5mm Hence small polyps can be removed and this can reduce cancer incidence It is usually performed under sedation Bowels need to be cleared before hand
35
Descirbe what **CT colonoscopy** entails and how it is relevant to colorectal cancer
Can only vsulaixe lesions **more** than 5 mm No need for sedation Less invasive and better tolerated by patients Bowels needs to be cleared before hand by not eating and taking laxatives If lesions is identified, patient will need colonoscopy for diagnosis
36
What is MRI of pelvis used for in colorectal cancer
Mainly for cancer in rectum it checks depth of invasion and mesorectal lymph node involvement there's no need for emptying bowels before hand. Also no sedation required it helps to choose between preoperative chemoradiotherapy or going straight to surgery
37
Why do we need to have a CT of chest/Abdo and pelvis for patients with colorectal cancer
For staging of cancer prior to treatment
38
What are the management options for colorectal cancer
NORMALLY managed by surgery howver there could be stent/radiotherapy or chemotherapy
39
What is the surgical procedure for an Obstructing colon carcinoma in the **right and transverse colon**
Resection and primary anastomosis
40
What is the surgical procedure for an Obstrucitng colon carcinoma in the **left side of the colon** ; i.e. descending and sigmoid colon
**Hartmann's procedure** - proximal end colostomy. There could be reversal in 6 months Primary anastomoses this involves : * Intraoperative bowel lavage with primary anastomoses * Defuncitoning ileostomy Palliative stent
41
Describe right hemicolectomy and extended right hemicolectomy
In **extended** right, there's resection in a portion of transverse colon unlike normal right
42
Describe left sided cancer resection
43
Describe the resection and anastomoses procedure in rectal cancer . Any danger with this operations
A part of sigmoid colon is cut and end of rectum is cut anus and sigmoid colon stitched back together There's no good blood supply here so this is a complication
44
What are the liver cancers
HCC- Hepatocellular carcinoma Gallbladder cancer Cholagiocarcinoma (ChCA) Secondary liver metastasis (CRC)
45
For hepatocellular cancer ; what is te aeitolgy and median survival time without intervention
Aetiology- * aflatoxin * 70-90% have underlying cirrhosis Median survival time without Rx - 4-6months
46
For Hepatocellular carcinoma what Rx options are effective and ineffective
Systemic chemotherapy INEFFECTIVE Other effective Rx options are: * OLTx * RFA- radio frequency ablation * TACE -trans arterial chemoembolization MOST EFFECTIVE: * surgical excision with curative intent.
47
Why is surgical excisions most effective Rx for HCC. Hw many of the patients are suitable for this surgery?
More than 30% have 5 yr survival however only 5-15% suitable for this type of surgery
48
What is the aetiology for gall bladder cancer ? what is the median survival time without Rx what is the 5 yr survival period
Aetiology unknown however it could be: * Gallstones * Porcelain Gall bladder * chronic typhoid infection median time without Rx - 5-8m 5yr survival is less than 5%
49
What are effective and ineffective interventions for Gallbladder cancer
INEFFECTIVE- systemic chemotherapy EFFECTIVE Optimal Rx is **surgical excision** with curative intent * 5 yr survival is **64% for stage 2**; **44% for stage 3**; and **8% for stage 4** * however **less than 15% of pt suitable for surgery** NO other effective Rx options
50
What is the aetiology and survival for Cholangiocarcinoma
Aetiology: * PSC (primary sclerosing cholangitis) and UC * liver fluke- (clonorchis sinesis) parasite * choledochal cyst Median survival without Rx is less than 6 months 5yr survival for less than 5%
51
What are the ineffective and effective interventions for Cholangiocarcinoma . Give details
INEFFECTIVE- systemic chemotherapy EFFECTIVE OPTIMAL: surgical excision with curative intent * 5 yr survival 20-40% * only 20-30% suitable for surgery no other effective Rx
52
What is the aetiology and survival rate of secondary liver metastases
Aetiology - * 15-20% synchronous with another cancer at the same time * 25% metachronous - occurs **6 month after** index cancer 5yr survival is 0% Median survival; without Rx is less than 1 year
53
What are the effective treatment options for CRC- secondary liver metastases . Give details like survival rate and % suitable for it.
Systemic chemotherapy improves it RFA (**Radio frequency ablation**) and SIRT (Selective internal radiotherapy) are also effective OPTIMAL Rx is **surgical excision** with curative intent. * **5yr survival is 25-50%** * **only 25% are suitable for surgery**
54
What drugs are most effective for increasing survival rate of CRC
IFL and BV LEAST EFFECTIVE is only best supportive care without drugs . Also 5-FU/LV
55
There are different locations of colorectal cancer . What's % is which ones and give any surgical relevance
2/3 cases are in descending colon and rectum 1/2 are in sigmoid colon and rectum - hence within reach of flexible sigmoidoscopy the rest in caecum and ascending colon
56
Descirbe the epidemiology of Pancreatic cancer
Incidence and mortality is roughly equivalent - almost 90% 2nd most commonest cause of cancer death more men have it than women Rare before age 45, 80% occurs between 60-80-years of age although not a common cancer but it leads in cancer deaths
57
What's the commonest form of pancreatic cancer? Does it have any SPECIFC symptoms?
Pancreatic ductal adenocarcinoma (PDA) no specifc symptoms for diagnoses
58
For pancreatic cancer; how many % of pt have late presentation and resectable disease. Give survival rate for each
**Late presentation: 80-85%** * median survival is less than 6 months * 5 yr survival is 0.5-5% Resectable disease- 15-20% * median survival is 11-20months * 5 yr survival is 20-25% * virtually all patients dead within 7 years of surgery
59
What are the risk factors for pancreatic cancer
* Chronic pancreatitis - highest risk factor * Type 2 diabetes - sometimes cancer is present before onset of type 2 diabetes * diet - **weak** risk factor * Choleithiasis, previous gastric surgery and pernicious anemia- **weak** risk factor * Cigarrettes smoking- strong * family history - increased risk by 2, 6 and 30 fold if you have 1, 2 and 3 first degree relative respectively * Occupation- insecticides, aluminium , nickel and acrylamide
60
Inherited syndromes increases lifetime risk of PDAs (Pancreatic ductal adenocarcinoma). One of the inherited syndrome is Hereditary pancreatitis. what gene is responsible for this? What is the function of the gene and whats the lifetime risk of getting PDA
61
Mutations in what gene would cause Familial atypical multiple mole melanoma what is the function of the gene what is the associated lifetime risk of PDA
62
What are the genes responsible for Familial breast ovarian cancer syndrome what is the function of the gene What is the lifetime risk of getting PDA
63
What is the gene responsible for Peutz-Jeghers syndrome what is the function of the gene what is the associated lifetime risk of getting PDA
64
What are the genes responsible for HNPCC/lynch syndrome what is the function of the gene what is the lifetime risk of getting PDA
65
What is the gene responsible for FAP syndrome what is the function of the gene what is the increased lifetime risk of getting PDA
66
Describe the pathogenesis of PDAs (pancreatic ductal adenocarcinoma)
PDAs evolve through non-invasive neoplastic precursor lesions hence in normal MPD, **PanINs develops (Pancreatic Intraepithelial Neoplasias)** PanINs 1, 2 and 3 develops as they acquire clonally selected genetic and epigenetic alterations along the way then cancer forms N.B PanINs cant be seen on imaging - only on microscope
67
What are the clinical presentation of carcinoma of the head of the pancreas- where 2/3 of PDA arise in
Jaundice - 90% present with this Weight loss due to malabasorption and also diabetes Pain in epigastrium that radiates to the back Acue pancreatitis attack Persistent vomiting results in duodenal obstruction Gastrointestinal bleeding - caused by duodenal invasion or varices secondary to partial or splenic vein obstruction
68
In head of pancreas PDA, what does back pain indicate
Posterior capsule invasion and irresectabiltiy
69
In patients with head of pancreas PDA, what else can you find alongside jaundice
Palpable gallbladder - Courvoiser sign
70
Descirbe the clinical presentations of PDAs of body and tail of pancreas
Develop insidiously and are asymptomatic in early stages At time of diagnosis the lesions at body and tail are more advanced than ones in head Jaundice is uncommon Vomitng occurs at late stage due to invasions of the DJ flexure wieght loss is apparent in 60% most of the time it is unresectable at time of diagnosis
71
What investigations can you do to find out if there's PDA and type of PDA.
Endoscopic ultrasounds scan laparoscopy and laparoscopic ultrasound PET MRI MRCP ERCP
72
What is the significance of MRI and MRCP in investigations for pancreatic cancer
MRI- this detects and predicts resectability with accuracies similar to CT MRCP- provides ductal images without complication of ERCP
73
What's the significance of ERCP in pancreatic cancer investigation
Confirms the **typical double duct** sign - head of pancreas cancer it involves aspiration/brushing of the bile-duct system therapeutic modality used in biliary stenting to relieve jaundice
74
What is the significance of PET and Laparoscopy/laparoscopic ultrasound in investigations for pancreatic cancer
PET- mainly used for demonstrating occult metastases Laproscopy - detect radiologically occult metastatic lesions of liver and peritoneal cavity add diagram
75
What is the significance of using Endoscopic ultrasound scan in investigations for Pancretic Cancer
Highly sensitive in detection of small tumours Useful in assessing vascular invasion Also involves fine needle aspiration
76
Describe what head of pancreas resection entails
**Whipple procedure**- removal of head, gallbladder, duodenum and small part of CBD. Remaining structures attached
77
Describe what Tail of pancreas resection entails
Research this
78
What can ultrasonography and dual phase CT scan show? In pancreatic cancer
79
What tumour marker is elevated in pancreatic cancer? Give other relevant and pertinent clinical significance of this marker When is it falsely elevated ?
***CA19-9*** Concentration more than 200U/ml shows high **sensitivity to PDA** Concentration in thousands shows **high specificity to PDA** however be aware that this marker is also falsely elevated in **pancreatitis**, hepatic dysfunction and **Obstructive jaundice**
80
Labels what class of PanIN this is
BRS1 - Valentine
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