17. Oncology: Pathlogies Flashcards
Lung Cancer
The peak incidence of lung cancer is between 60–70 years of age.
• More commonly affecting men (3:1).
• Second most common malignancy in men.
• Five-year survival rate of 15%.
• 95% arise in bronchi. Diagnosed by x-ray.
• 90% due to smoking. Frequently follows COPD.
• A study found that a diet rich in fruit and vegetables reduces the incidence of lung cancer by 25%.
• Most commonly secondary (colorectal, osteosarcoma, prostate)
Lung Cancer: Signs and Symptoms
- Dry and persistent cough.
- Dyspnoea and chest pain.
- Weight loss and voice hoarseness.
- Haemoptysis (bloody / raspberry sputum).
- Wasting of muscles in hand (if apical tumour).
- ‘Clubbing’ of nails.
Lung Cancer: Investigations
Sputum culture
FBC
chest X-ray
CT scan
Lung Cancer: Treatment
Radio / chemotherapy, surgery.
Colorectal Cancer
Locally invasive but metastatic spread may be evident before growth produces symptoms.
• Metastasises to the liver, lungs, brain and bone.
• Common over 50 years of age.
• More common in developed countries.
• Screening in developed countries often involves stool analysis and endoscopy (looking for occult blood in stool).
• Five-year survival: Stage I = 93%. Stage IV = 3%
Colorectal Cancer: Risk Factors
Strong link with a diet high in meat, low in fibre, lack of vitamin D. Polyps, family history.
Colorectal: Signs and Symptoms
- Initially few symptoms.
- Rectal bleeding, blood / mucus in stool.
- Obstruction causing colicky abdominal pain.
- Anaemia -> fatigue, pallor, etc.
- Consistent change in bowel habits (diarrhoea / constipation).
Colorectal Cancer: Investigations
- Colonoscopy and biopsy. Stool analysis (occult blood and M2-PK).
- Blood test (CEA and inflammatory markers).
Colorectal Cancer: Treatment
Radio - internal
Chemo
Surgery
Palliative
Benign Breast Masses
Most breast lumps are benign. These will generally be either cysts or fibroadenomas.
• Fibrocystic breast disease often presents as breast pain / tender masses / nodules:
- Most prevalent in pre-menstrual women and cysts often shrink following the onset of menses.
• Benign breast tumours are typically mobile, smooth and have regular borders. This differs from a malignant mass.
• Hormones are thought to be critical in aetiology.
• It is worth highlighting that breast pain is not usually associated with breast cancer.
Breat Cancer
Breast cancer is the most common female cancer.
• Either ductal or lobular epithelial cells.
• Breast cancer can also affect men (1% of breast cancer cases).
Breast Cancer: Signs and Symptoms
- Asymptomatic usually.
- Painless, unilateral fixed lump (benign breast tumours are very common and typically present as mobile lumps).
- Overlying skin changes; i.e. dimpling, ‘orange peel’ appearance.
- Asymmetry of breasts, inverted and discharging nipple.
- Enlarged axillary lymph nodes.
Breat Cancer: Risk Factors
• Breast cancer cells contain receptors that hormones or other proteins can bind to and promote tumour growth.
- These receptors are most commonly for oestrogen (80%).
- The two other receptor types are for ‘progesterone’ or ‘epidermal growth factor’.
- If a tumour contains none of the three receptor types, the breast cancer is ‘triple negative’. This accounts for 15% of cases.
• Therefore, most breast cancer is known to be associated with oestrogen. High oestrogen exposure increases risk. This exposure can include endogenous and exogenous oestrogen.
Breast Cancer: Risk Factors (1)
- Oestrogen has the ability to promote the growth of breast cancer cells (as it does at puberty and in pregnancy). Oestrogen is a hormone that will always promote growth in the body.
- BRCA1 or BRCA2 mutations increase the risk of breast (and ovarian) cancer. However, it is essential to consider the environment these genes are bathed in! These mutations only account for 5% of all breast cancers.
- A longer ‘reproductive life’ (early menarche, late menopause = higher oestrogen exposure), the combined oral contraceptive pill and HRT.
- BPA (a chemical in plastics) — mimics oestrogen.
Breast Cancer: Risk Factors (2)
- IGF-1 (cow milk) promotes breast cancer in women with high oestrogen levels.
- Breast quadrants and breast cancer:
- Once oestrogen is metabolised, it has to leave the breast via the upper lateral quadrant, where most cancers occur.
- Aluminium is found within many antiperspirants, which may be absorbed and cause oestrogen-like hormonal effects.
- Parabens in deodorants can also mimic oestrogen (found in breast tumours).
- Upper medial quadrant tumours are becoming more common (mobile phones?).
Breast Cancer: Diagnosis
• Mammography:
- An X-ray that directs radiation into breasts.
- Mammography looks for the presence of tumours. These tumours would need to reach a certain size before becoming visible on an
X-ray (the tumour didn’t just ‘appear’).
• Mammography increases breast cancer risk!
• Thermography:
- A safer and more effective method of detecting earlier pathological cancerous changes.
- As already mentioned, as cancer cells divide, they must undergo angiogenesis (this increases the local temperature).
Breast Cancer: Complications
•Metastatic spread via lymphatics.
Breast Cancer: Treatment
- Radiotherapy, chemotherapy, surgery.
- Hormonal therapy: If oestrogen positive — tamoxifen (blocks oestrogen receptors). This can cause hot flushes, joint pains, osteoporosis, DVT and sleep irregularities.
Ovarian Cancer
Ovarian cancer mostly affects women over 40 years of age.
• Most lethal gynaecological malignancy.
• Ovarian cancer is generally oestrogen dependent, like breast cancer.
Ovarian Cancer: Risk Factors
- Family history.
- BRCA 1 and 2.
- Late menopause, early menarche.
- Infertility / never given birth.
- HRT.
- Poor lifestyle: Exercise, smokers, obesity.
- Diet rich in animal fats.
- Talcum powder used between legs.
Ovarian Cancer: Signs and Symptoms
- Early stage asymptomatic.
- Vague abdominal discomfort and bloating.
- Abdominal mass with pelvic pain.
- 75% present with advanced disease Later: Change in bowel habits.
Ovarian Cancer: Diagnosis
- Ultrasound.
- CT, MRI.
- Bloods: CA-125 tumour marker
Ovarian Cancer: Prognosis
38% - five-year survival
Cervical Cancer
Most common cancer in young women. Commonly 25–35 years of age.
• 20% of all cancers in women.
• 4,500 cases per year.
Cervical Cancer: Risk Factors
- Persistent HPV infection (16 + 18 cause 70%).
- Sexual behaviour (multiple partners, younger age).
- Smoking, COCP.
Cervical Cancer: Screening
- 30% detected by screening.
* ’Smear’: To detect cancerous and pre-cancerous changes.
Cervical Cancer: Signs and Symptoms
- Non-specific symptoms.
- Abnormal vaginal bleeding (after sexual intercourse, between menstrual periods).
- Vaginal discharge.
- White / red patches on cervix.
Cervical Cancer: Diagnosis
Biopsy and histological examination. MRI, CT.
Cervical Cancer: Treatment
Surgical - historectomy (preferred up to stage 2)
Chemo-radioo therapy
Liver Cancer
- Primary or secondary (spread from another tissue).
- Usually co-exists with liver cirrhosis.
- More commonly affecting men, peak ~ 60s.
Liver Cancer: Signs and Symptoms
- In the advanced stages: Jaundice, ascites, hepatomegaly.
- Pruritus (itchy skin), bleeding oesophageal varices (secondary to portal hypertension), weight loss.
- Vomiting, loss of appetite, feeling very full after eating, feeling sick, pain or swelling in the abdomen, fatigue and weakness.
Liver Cancer: Causes
- Associated with liver cirrhosis: Alcohol, toxins -> necrosis > chronic inflammation and cell proliferation (turnover).
- Hepatitis B / C -> viral integration into host genome (host DNA deletions; oncogenes activated).
Liver Cancer: Treatment
Surgery - Transplant
Gastric Cancer
Second highest cause of cancer-related deaths in the world (higher rates in Eastern Asia, with the highest rates worldwide being Korea and Japan).
Gastric Cancer: Causes/Risk Factors
Diet rich in salted, pickled and smoked foods (N-nitroso compounds).
•Male, smoking, age (55 yrs+).
•H. pylori infection.
•Low fruit and vegetable diet.
Gastric Cancer: Diagnosis
- Blood in stool. Endocopy, biopsy.
* Tumour markers: CEA and CA 19-9.
Gastric Cancer: Signs and Symptoms
Early stages:
• Persistent indigestion, frequent burping, heartburn, feeling full quickly when eating, bloated, abdominal discomfort.
Advanced stages:
• Black blood in the stools, loss of appetite, weight loss, tiredness, anaemia, jaundice.
Gastric Cancer: Treatment
Gastrectomy, chemo/radiotherapy
Oesophageal Cancer
A common aggressive tumour with a poor prognosis.
Oesophageal Cancer: Signs and Symptoms
- Few early symptoms, later obstruction may occur.
- Dysphagia (red flag!).
- Anorexia and melaena (due to oesophageal bleeding).
Oesphageal Cancer: Causes and Risk Factors
- Chronic irritation, alcohol, smoking.
- GORD and Barrett’s oesophagus.
- Obesity, low fruit and veg diet, age.
Pancreatic Cancer
Common in older people, uncommon in people under 40 years; poor prognosis.
• Most arise from the exocrine cells.
• Less commonly from endocrine Islet cells (‘pancreatic neuroendocrine tumour’).
• Approx. 60% metastatic at diagnosis.
Pancreatic Cancer: Causes
- Cause is unknown, but risks include: age, smoking, family history (germ line defects in 5–10%).
- Other health conditions (chronic pancreatitis, diabetes, H. pylori).
Pancreatic Cancer: Signs and Symptoms
- Asymptomatic early.
- Epigastric pain radiating to the back.
- Unexplained weight loss, anorexia and fatigue.
- Jaundice.
- Post-prandial nausea.
- Glucose intolerance (neuroendocrine tumours).
Pancreatic Cancer: Treatment
Surgery, chemo/radio
Prostate Cancer
Most common cancer in men. Generally 50+ years. Increasing incidence.
•90% of prostate cancer never grows out of the capsule.
Prostate Cancer: Signs and Symptoms
- Same urinary symptoms as BPH.
- Key symptoms include nocturia and haematuria.
- Back pain can indicate bone metastases.
Prostate Cancer: Investigations
- Elevated PSA.
- Digital rectal examination.
- Biopsy.
Prostate Cancer: Risk Factors
- Increasing age: Mainly affects men over 50 years old.
- Diet: High red meat intake (especially processed, non-grass fed), high diary intake (with raised IGF), acidic.
- Ethnicity: Men of black ethnicity are at the highest risk of developing prostate cancer.
- Family history: The risk of developing prostate cancer will increase depending upon the number of relatives affected.
- Genetics: Associated with genes such as BRCA1/2.
- Obesity: Anabolic steroid use.
Prostate Cancer: Treatment
- Radiotherapy (localised, non-invasive).
- Androgen deprivation therapy.
- Chemotherapy.
- Surgery (removal) — 50% never recover urinary / erectile function
Bladder Cancer
Two times more common in men and most common in the 70–80 year age group.
• Commonly originates from transitional epithelial cells in the bladder.
Bladder Cancer: Causes and Risk Factors
- Smoking (amines / hydrocarbons = carcinogens -> pool in the bladder and induce mutations).
- Chronic cystitis, increasing age, catheterisation.
Bladder Cancer: Signs and Symptoms
- Painless haematuria (90%).
- Increased urine frequency, urgency, dysuria.
- Bone metastases (with pain; e.g. in spine)
Bladder Cancer: Treatment
Transurethral resection or cystectomy
Testicular Cancer
Most common cancer in young men (15–35 yrs).
• Higher risk if undescended testis and family history.
• Excellent prognosis if caught early: Orchidectomy.
Testicular Cancer: Signs and Symptoms
- Hard, painless, unilateral mass.
- Dragging sensation and dull ache.
- Metastasises to bone, brain, lungs and liver.
Testicular Cancer: Support
- Regular, monthly self-examination.
- Herbs, nutritional supplements — antioxidants, diet is essential for all forms of cancer (primarily plant-based diet rich in nutrients and antioxidants). Homeopathy and acupuncture.
Skin Cancer
Visible, generally easily detected and develops slowly = good prognosis.
• Highest rate of re-occurrence.
• Usually arises on head, neck or back (sun-exposed areas mostly commonly).
• Most common in fair skinned people aged 40+.
• Cases are on the increase. Strong connection to UV light exposure and the chemicals in sunscreens.
• Skin cancer types differ based on the cells affected.
Basal Cell Carcinoma
The most common skin cancer.
• Raised, smooth, pearly bump on the sun-exposed skin of the head, neck or shoulders.
• Sometimes small blood vessels can be seen within the tumour.
• Crusting and bleeding in the centre of the tumour is often mistaken for a sore that does not heal.
• Good prognosis and with proper treatment can be completely eliminated, often without scarring.
Squamous Cell Carcinoma
Malignant tumour from keratinised epithelial cells.
• Second most common skin cancer.
• A red, scaling, thickened nodule / patch on sun-exposed skin.
• Some are firm hard nodules with central necrosis = ulcer / bleeding.
• When not treated, it may develop into a large mass.
• It is dangerous, but not nearly as dangerous as a melanoma.
Melanoma
Most spread out within epidermis (can be in-situ). Women > men 30–50 yrs.
• Risk factors: Pale skin, sun exposure.
• Often brown / black lesions, occasionally pink or red in colour.
• Warning signs that might indicate a malignant melanoma include change in size, shape, colour; elevation of a mole or new mole.
• Five-year survival = 80%.
• Surgical, chemotherapy.Most spread out within epidermis (can be in-situ). Women > men 30–50 yrs.
• Risk factors: Pale skin, sun exposure.
• Often brown / black lesions, occasionally pink or red in colour.
• Warning signs that might indicate a malignant melanoma include change in size, shape, colour; elevation of a mole or new mole.
• Five-year survival = 80%.
• Surgical, chemotherapy.
Bone Tumours
Bone tumours can be benign or malignant.
• An ‘osteosarcoma’ is a malignant bone tumour.
• Primary osteosarcomas most commonly affect teenagers and typically occur around the knee or in the humerus (i.e. consider knee pain?).
• Primary osteosarcomas rapidly metastasise (often to the lung).
• Malignant bone tumours are most commonly secondary tumours. The spine is commonly affected due to a venous network in the spine.
• Malignant bone tumours cause worsening pain that becomes unremitting. The pain can wake the patient at night and causes systemic symptoms; e.g. weight loss, malaise, fatigue, night sweats.
Brain Tumours: General
Both benign and malignant brain tumours account for significant mortality. As these tumours grow, they cause severe effects due to the
space-limiting structure of the cranium.
• Brain tumours that grow rapidly aggressively are often referred to as ‘high-grade tumours’, whilst slower replicating tumours are ‘low-grade’.
• High-grade tumours include ‘gliomas’ and ‘glioblastomas’, whilst low-grade tumours include ‘meningiomas’.
• Most intracranial tumours are metastases from other tumours (10 x more > primaries). Common primary sites include the lung, breast, stomach and prostate.
Brain Tumours
- Brain tumours can occur at any age but most commonly occur in those aged between 50–70, as well as children / young adults.
- Possible links with mobile phone use.
Brain Tumours: Signs and Symptoms
- Unexplained headaches — worse in the mornings.
- Vomiting and nausea, seizures.
- Double vision, behaviour changes, slurred speech.
- Signs: Papilloedema.
Brain Tumours: Treatment
Surgery (often dependent on location) or radiotherapy (external beam).
Lymphoma
Lymphoma describes a malignancy of lymphatic cells (i.e. cancer of the lymphatic system). Differs from leukaemia where the malignancy arises from the bone marrow.
•There are two main types of lymphoma: Non-Hodgkin’s and Hodgkin’s lymphoma.
•Non-Hodgkin’s lymphoma is five x more common.
•Most lymphomas involve B-lymphocytes.
•Non-Hodgkin’s: peak age 50 years+ and children / young adults.
•Hodgkin’s: peak age 20–35 years and is also a common paediatric malignancy.
Lymphoma: Risk Factors
- The Epstein-Barr virus (EBV) has been found in 50% of patients with Hodgkin’s lymphoma.
- Other risk factors include HIV and general immunosuppression.
- Exposure to pesticides and herbicides, chemotherapy and radiotherapy.
Lymphoma: Signs and Symptoms
- Commonly presents as an enlarged and asymptomatic lymph node in neck.
- Chest discomfort, cough, dyspnoea.
- Drenching night sweats, fever, weight loss.
- Lymphadenopathy, hepatomegaly, splenomegaly.
Lymphioma: Diagnosis
- Biopsy of lymph node (surgical or fine needle).
* Blood tests: Raised ESR, leukocytosis, lymphopenia, anaemia and HIV testing
Lymphoma: Treatment
•Chemotherapy is the main treatment approach (however, this is well recognised to cause secondary tumours!)
Leukaemia
‘Leukaemia’ describes a group of bone marrow cancers, characterised by an abnormal over-production of leukocytes.
•This uncontrolled proliferation results in supressed erythrocyte production (= anaemia) and thrombocytes (= thrombocytopenia).
Divided into:
•Acute leukaemias: Rapid onset, more aggressive course. Immature cells (>20% -blast cells in bone marrow).
•Chronic leukaemias: Insidious onset and more differentiated cells.
Leukaemia: Acute
Age: All ages. Onset: Sudden. Leukaemic cells: Immature (-blasts). Anaemia: Prominent. Thrombocytopenia: Prominent. Leukocyte count: Variable. Lymph node enlargement: Mild. Splenomegaly: Mild.
Leukaemia: Chronic
Age: Usually adults. Onset: Insidious. Leukaemic cells: Mature. Anaemia: Mild. Thrombocytopenia: Mild. Leukocyte count: Increased. Lymph node enlargement: Prominent. Splenomegaly: Prominent.
Leukaemia: Types
- Acute myelogenous leukaemia (AML).
- Acute lymphocytic leukaemia (ALL).
- Chronic myeloid leukaemia (CML).
- Chronic lymphocytic leukaemia (CLL).
Leukaemia: Signs and Symptoms
- Malaise, anaemia (fatigue, pallor etc.), frequent infections, easy bleeding / bruising.
- Fever, weight loss.
- Splenomegaly (abdominal swelling / discomfort).
- Lymph node enlargement.
Leukaemia: Diagnosis
- Full blood count: Anaemia, low thrombocytes, variable leukocyte count.
- Blood film (viewing sample of blood).
- Bone marrow biopsy.
Leukaemia: Treatment
Chemotherapy
Bone Marrow Transplant
