Esophageal Cancer Past Paper 2023/24 PDF

Charlotte Eikaas 2023/24 ESOPHAGEAL CANCER EPIDEMIOLOGY DIAGNOSIS mostly advanced at...

Charlotte Eikaas 2023/24 ESOPHAGEAL CANCER EPIDEMIOLOGY DIAGNOSIS mostly advanced at stage - Rare- 1% of all cancers: western world = AC; whole Gastroscopy with biopsy world = SCC EUS- endoscopic USG M >F CT AA: 45+ for SCC, 70 for AC Liver parameters DISTINGUISING SUBTYPES pacitaxel > - TREATMENT: mostly Squamous cell carcinoma: * endoscopically > - carboplatin Surgery = usually best option; +/- pre-op RT/chemo t Risk factors: alcohol + smoking (MC), low socioeconomic Inoperable → radical chemoradiotherapy post-op immunoth standard, poor diet, hot beverages, nitrosamines in diet, Intracavital brachytherapy irradiation, HPV, achalasia, Plummer-Vinson syndrome, Metastatic → symptomatic treatment + chemot immuno [ ] chemical injury (Nivolumab) Peri-op chemo is used-cancer ↳ also in lower esophagus Location: usually in middle third gastric cancer PROGRESSION & PROGNOSIS Adenocarcinoma: also processed meat. No Poor prognostic factors: tumor >5cm, weight loss >10%, Risk factors: Barrett’s esophagus ( GERD), obesity, tobacco, esophageal obstruction, high grade tumor radiation; protective factors = healthy diet, H.Pylori Metastasis: lymphatic spread to lungs, liver or adrenal Location: usually in distal third glands Generally not great prognosis PRESENTATION Dysphagia Odynophagia Weight loss: if >10% = poor prognostic factor Vomiting Cough Hoarseness- recurrent laryngeal n. paralysis Dyspnea 15  Oxyplatin Anti-EFGR Treatment (Panitumumab) ↳ induced Neuropathy ↳ d skin toxicity steroid give doxycline/oral ↓ close or stop treatment ↳ Charlotte Eikaas 2023/24 COLON CANCER > - mostly develop from polyps - so endoscopic removal of polyps/adenomas - I risk. EPIDEMIOLOGY DIAGNOSIS: based on colonoscopy with biopsy 3rd MC cancer- most common cancer of GIT After biopsy results: CT abdomen + chest- search for Responsible for 10% of cancer deaths- 3rd MC metastasis Peak incidence 60-70 y/old; M=F Molecular testing: KRAS, NRAS, BRAF, MSI, HER2, FAP; if positive for Lynch/FAP → checkup on family members Id risk in ppe who take aspirin or RISK FACTORS & ETIOLOGY high fiber diet) Staging: DUKES, ASTLER-COLLER or AJCC/TNM Genetic: only 5% of cases; FAP, Lynch syndrome, juvenile polyposis, Peutz-Jeghers TREATMENT- SURGERY +/- other options ↳ (min lymph nodes 12) remove. IBD- UC (>) Crohn’s Stage I + II: resection is the best option Poor diet- refined carbs, no fiber, rich in fat Stage III: surgery +/- post-op chemo Blood group O = higher risk alcohol obesity processed meat Stage IV: chemo + surgery- removing tumor + mets smoking negative , , , Chemo (FOLFOX) + Panitumumab (anti-EGFR) if positive SUBTYPES for KRAS/BRAF mutation; note severe skin toxicity- anti- Vast majority are adenocarcinomas without inherited actually good predictive sign most commonly VEGF (r) is added genetic mutations; most develop from adenomas- NO RADIOTHERAPY ↳ Bevacizumab. higher risk if large, dysplastic/metaplastic, sessile or flat, villous architecture, multiple polyps PROGRESSION & PROGNOSIS FAP- familial adenomatous polyposis (AD; APC mutation): results in extreme polyp formation in 20-25% are diagnosed at metastatic stage- MC = liver adolescence; 100% risk of colon cancer at 55 y/old- Prognostic factors: grade + lymphatic invasion + >4 lymph colon must be surgically removed. ↑risk of many nodes involved + presurgical CEA >5 other cancers- gastric, thyroid, hepatoblastoma 50% of patients after surgery will relapse; 80% of relapses HNPCC/ Lynch syndrome (AD, MSI); also high risk of within 3y after surgery other malignancies- endometrial, gastric, ovarian, renal and intestinal cancer; NOT sensitive to 5-FU; OTHERWISE NOTEWORTHY right-sided cancer MC Screening: annual DRE from 40; fecal occult blood test from 50; if positive → colonoscopy; if higher risk patients PRESENTATION → colonoscopy every 10y from 50; reduce risk by 30% CEA: marker for several cancers, also colon cancer; cannot Iron deficiency anemia + blood in stool- tumor bleed be used for screening, but good for monitoring treatment Altered bowel habits- diarrhea, constipation Locations of cancer within large intestine: left colon + Hematochezia sigmoid (36%) > right colon + cecum (27%) > rectum > Abdominal pain transverse colon > anus > other Ileus- risk of obstruction Suggesting right-sided cancer: anemia chemo- About 1 - Not required Suggesting left-sided cancer: obstruction, pencil-shaped stool 2-1dmg-capecitabine or 5-fu > - In pts with MSI > Immunotherapy Nivolumab/ 4-2digs-FOLFox-S-fr CAPOX-capecitabine 7 - 3 - J Pembrocismal , + oxiplatin R mostly Lynch syndrome ① also ipilimumab Palliative - ext also add Irinotecan 16 ↳. you may I FOLFOXIRI => KRAS is predictive When using anti-EFGR-ree.  Charlotte Eikaas 2023/24 RECTAL CANCER EPIDEMIOLOGY DIAGNOSIS Less prevalent than colon cancer Colonoscopy with biopsy 16% of colorectal cancers CT/MRI to assess for metastasis RISK FACTORS & ETIOLOGY: essentially the same as colon TREATMENT: cancer Stage I + II → surgery- TME- total mesorectal excision Stage III → pre-op RT + surgery +/- post-op chemo SUBTYPES: Stage IV → surgery + chemo/RT Adenocarcinoma- vast majority SCC PROGRESSION & PROGNOSIS Neuroendocrine tumors 5YS DUKES: A=80-90%, B= 70-80%, C= 30-50% PRESENTATION Bleeding from anus- more typical for rectal cancer than colon cancer Constipation and/or diarrhea Abdominal pain- often crampy 17  Charlotte Eikaas 2023/24 ANAL CANCER EPIDEMIOLOGY DIAGNOSIS: biopsy M >F (4x) Female gender = Peak incidence in 50s RISK FACTORS & ETIOLOGY: TREATMENT: (surgery is not preferred. HPV (16,18)- genital warts; 30x risk Should be conservative- preserve anal sphincter: chemo Immunodeficiency- HIV, immunosuppression + RT = curable in 80-90% Anal intercourse- 33x If - Correa cascade - Normal gashic mucosa ↓ chromic bit is gas Charlotte Eikaas 2023/24 ↓ Gashic Anophy intestina metaplas in GASTRIC CANCER ↓ Cancer Dysplasia > - EPIDEMIOLOGY - Adenocarcinoma. mostly DIAGNOSIS MC in Japan and China; decreasing incidence Gastroscopy with biopsy Relatively common cause of cancer death CT to assess for metastasis M >F, AA 60 y/old RISK FACTORS & ETIOLOGY: many RFs depend on subtype; others include… TREATMENT in early stages Ne Adenomatous gastric polyps Surgery = only radical treatment- either total or partial - Partial gastrectomy gastrectomy + lymphadenectomy (D2 pergas hictaround cla > - a Family history, blood group A Radical resection of stage IB or higher → combine with chemo Herceptin: used in around 20%- for specific mutation SUBTYPES > - locally advanced - Pre-op chemo - surgery > - post-op chemo. ↓ ↳ ↳ I 95% are adenocarcinomas; two subtypes exist (Lauren 5- Fu 11 cycles immuno- if PDL-S the A cycles Leucovorin Trastuzumal if HER2 the classification) Oxiplatina (FLOD) 1. Intestinal AC - > More common. Decreasing incidence; MC in Japan PROGRESSION & PROGNOSIS M>F, average age 55 Very poor prognosis- T1 = 50% 5YS, stage IV = 3% Related to chronic gastritis (H.Pylori), Spread: direct to GIT, or hematogenous- to liver or to nitrosamines, FAP and HNPCC ovaries- Bilateral mucinous AC- Krukenberg tumor 2. Diffuse AC Stable incidence Uniform across countries, M=F OTHERWISE NOTEWORTHY May be related to EBV- better prognosis Related to CDH1 mutation (Cadherin loss) (1 - 3 % ) Specific lymph nodes associated: Virchow’s node (= also CTNNAI Troisier sign-metastasis to left supraclavicular from PRESENTATION abdominal cancer), left axillary nodes, Sister Mary Joseph’s node (periumbilical) Epigastric pain; sometimes also in back if advanced Vomiting; sometimes hematemesis Anorexia, weight loss Dysphagia Iron-deficiency anemia Hepatomegaly Lymphadenopathy Epigastric mass Paraneoplastic syndromes: Acanthosis Nigricans, Leser-Trelat syndrome 20  Charlotte Eikaas 2023/24 LIVER CANCER EPIDEMIOLOGY DIAGNOSIS 5th MC cancer worldwide USG, CT, MRI MC in Asia and Africa- higher prevalence of viral AFP level- increased in HCC; not diagnostic, not used for hepatitis screening Hepatic mass with typical image on CT/MRI in RISK FACTORS & ETIOLOGY (hepatocellular carcinoma) liver cirrhosis - allows diagnosis without biopsy does not work. Chronic hepatitis: HCV > HBV; HBC can cause HCC TREATMENT: chemo · Ablation (radio frequency/microwaves without cirrhosis Surgery may be curative in some cases transplantation , Cirrhosis- only 15-20% in non-cirrhotic livers; usually Inoperable → Sorafenib oval TK-Inhibitor > - 2 related to alcoholism and poor lifestyle USG every 6 months due to a risk. - also TACE (trans arterial chemoembolization M>F Aflatoxins (Aspergillus toxin in food) or mycotoxins PROGRESSION & PROGNOSIS PBC- primary biliary cholangitis Generally poor prognosis- hidden by cirrhosis; death due Genetic: beta-catenin, TP53, TERT to liver failure or complications of portal HTN Alpha1-antitrypsin deficiency also Wilsons disease hemochromatosis Tendency to invade portal vein obesity , , Intrahepatic metastasis = MC SUBTYPES: Hepatocellular carcinoma: MC primary subtype Fibrolamellar carcinoma: 85% 65 - Age years Obesity , Diabetes Primary Biliary Cholangitis Biliary stones Types - Gall Bladder Displatin + Gemcitabine unresectable/Metastatic - immuno - C+ -