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year 4 CDM 2 > ase 17: cancer breast, cervical, colorectal > Flashcards

ase 17: cancer breast, cervical, colorectal Flashcards

1
Q

bone metastasis

A
  • Common causes: breast, prostate, kidney and thyroid
  • Poor prognosis in breast cancer its 2 years
  • Aim is to prevent pain, preserve function and skeletal stabilisation
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2
Q

Malignant spinal cor compression

A
  • Investigation: urgent MRI of whole spine, give Dexamethasone straight away then neurosurgery or radiotherapy
  • Normal location: thoracic
  • Good prognosis if detected early
  • Breast cancer has highest incidence of spinal cord compression

Most common causes of neoplastic spinal cord compression: metastasis from breast, lung, prostate and renal cell

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3
Q

Signs and symptoms of malignant spinal cord compression

A
  • Signs: bilateral UMN signs below the compression, back pain especially coughing or lying flat, sensory changes one or two dermatomes below the level of compression (numbness or pins and needles).
    -Progresses to motor weakness and finally sphincter block
  • Hyperreflexia and hypertonia (spastic paresis)
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4
Q

Colorectal cancer epidemiology

A

Third most common cancer in the UK

Four most common cancers in the UK: Breast, Lung, Prostate, Colorectal

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5
Q

Colorectal cancer risk factors

A
  • Family and personal history of bowel cancer
  • African American
  • Familial adenomatous polyposis(FAP)
  • Hereditary nonpolyposis colorectal cancer(HNPCC), also known asLynch syndrome
  • IBD (Crohn’s or ulcerative colitis)
  • Increased age (>50), male
  • Diet (high in red and processed meat and low in fibre)
  • Obesity and sedentary lifestyle
  • Smoking, Alcohol
  • Developed countries
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6
Q

Colorectal cancer pathophysiology

A
  • 70% are adenocarcinomas which arise from benign adenomatous polyps.
  • These polyps (adenomas) are slow growing and few progress to malignancy. Increased risk with time and size
  • Metastasise to liver, lung, bone, brain and skin
  • Only 5% are associated with hereditary conditions
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7
Q

Histological types of colorectal cancer

A
  • Adenocarcinoma - most colon cancers - (mucinous (colloid) adenocarcinoma & signet ring adenocarcinoma
  • Scirrhous tumours
  • Neuroendocrine: Tumours with neuroendocrine differentiation typically have a poorer prognosis than pure adenocarcinoma variants
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8
Q

FAP

A

FAP: autosomal dominant condition causing malfunctioning of tumour suppressor gene resulting in polyps in the large intestine. Germ line mutation in the tumour suppressor gene APC

FAP extracolonic features: Congenital Hypertrophy of the retinal pigment epithelium (CHRPE), osteomas of the jaw, pre-pubertal epidermal cysts

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9
Q

Lynch syndrome

A
  • Germ line mutation in one of several DNA mismatch repair genes and carries a 40% lifetime risk of developing colorectal cancer
  • Autosomal dominant
  • Tend to develop colorectal cancer at 40
  • Lynch syndrome type II: ovarian, endometrial, gastric, urinary and hepatobiliary cancer
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10
Q

Colorectal cancer symptoms

A
  • Change in bowel habit (usually to more loose and frequent stools)
  • Unexplained weight loss
  • Rectal bleeding
  • Unexplained abdominal pain
  • Iron deficiency anaemia (microcytic anaemia with low ferritin)
  • Abdominal or rectal mass on examination
  • Bowel obstruction: severe abdominal pain, nausea and vomiting
  • Troiser’s sign: enlarged Virchow’s lymph node in the left SCF
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11
Q

Right and left sided colorectal cancer symptoms

A
  • Often asymptomatic till late stage
  • Right sided: palpable mass in RIF, diarrhoea, weight loss, anaemia and occult GI bleeding
  • Left sided: palpable mass in LIF, change in bowel habit (normally constipation), tenesmus, rectal bleeding and bowel obstruction. Tend to present earlier.
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12
Q

Criteria for two week wait for colorectal cancer

A
  • Over 40 years with abdominal painandunexplained weight loss
  • Over 50 years with unexplained rectal bleeding
  • Over 60 years with a change in bowel habit or iron deficiency anaemia
  • Test shows occult blood in their faeces
  • Adults with rectal or abdominal mass
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13
Q

Colorectal cancer investigations

A
  • bedside: full set of obs, PR exam (blood)
  • bloods: FBC to look for microcytic anaemia, U+Es for baseline, LFTs to look for liver mets, CEA (might be elevated, good to assess response to treatment)
  • imaging: colonoscopy is diagnostic- take biopsies. If unsuitable for colonoscopy perform a flexible sigmoidoscopy with double contrast barium enema. Contrast CT chest abdo pelvis for staging
  • special tests: biopsy taken during colonoscopy
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14
Q

Colorectal cancer management

A
  • Conservative:- MDT involvement esp post op (dietician, stoma nurse, physio)
  • Medical: chemo, radiotherapy
  • Surgical: hemi (majority) or total colectomy. Resection of lymph nodes if affected.
  • Metastasis: surgical resection
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15
Q

Colorectal cancer chemo

A
  • Metastatic disease (stage III): FOLIRI or FOLFOX first line. FOLFOX side effects: neutropenia and peripheral neuropathy
  • anti-EGFR targeted mAbs (cetuximab) with standard chemo are used in KARS wild metastatic colorectal cancer
  • VEGF targeted mAb (bevacizumab) in addition to standard chemo can increase survival
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16
Q

Colorectal cancer imaging

A
  • Colonoscopy: gold standard, can get biopsies
  • Sigmoidoscopy: endoscopy of rectum and sigmoid colon only, can miss cancer in other parts of the colon
  • CT colonography: can be considered in patients unfit for colonoscopy, less detailed doesnt allow for biopsies
  • Staging CT scan (CT thorax, abdomen and pelvis (CT TAP)): to look for metastasis and other cancer, can be used after diagnosis or for vague symptoms
  • CEA: can predict relapse not helpful in treating
  • Liver US: to assess for mets
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17
Q

staging colorectal cancer

A
  • TNM (tumour, node, metastasis)
  • Examine at least 12 lymph nodes
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18
Q

Colorectal cancer TMN

A
  • T: 0 no primary tumour, 1 tumour invading submucosa, 2 tumour invading muscle, 3 tumour invading through muscle, 4 tumour perforating the peritoneum
  • N: 0 no nodal involvement, 1 metastasis in 1-3 pericolic nodes, 2 metastasis in 4 or more peri-colic nodes, 3 lymph node involvement on named vascular trunk or apical node metastasis in any lymph node
  • M: 0 no distant metastasis, 1 distant metastasis
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19
Q

Operations in colorectal cancer

A
  • Right hemicolectomy: removal of thecaecum,ascendingandproximal transverse colon.
  • Left hemicolectomy: removal of thedistal transverseanddescending colon.
  • High anterior resection: removing thesigmoid colon(sigmoid colectomy).
  • Low anterior resection: removing thesigmoid colonandupper rectumbut sparing the lower rectum and anus.
  • Abdomino-perineal resection (APR)involves removing therectumandanus(plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
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20
Q

Hartmanns procedure

A

done for acute bowel obstruction due to tumour.Is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

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21
Q

Complications of surgery for bowel cancer

A
  • Bleeding, infection and pain
  • Damage to nerves, bladder, ureter or bowel
  • Post-operative ileus
  • Anaesthetic risks
  • Laparoscopic surgery converted during the operation to open surgery (laparotomy)
  • Leakage or failure of the anastomosis
  • Venous thromboembolism (DVT and PE)
  • Incisional hernias
  • Intra-abdominal adhesions
22
Q

Complications of bowel cancer

A
  • Metastasis: Liver most common. Then lung, bone, brain and skin
  • Obstruction
  • Perforated colon cancer: abdo pain, free air and diffuse peritonitis
  • Intestinal intussusception
  • GI bleed
23
Q

Bowel cancer follow up

A
  • Serum carcinoembryonic antigen (CEA) every 6 months
  • CT thorax, abdomen and pelvis x 2
  • Normally over 3 years
24
Q

Screening for bowel cancer

A
  • The Faecal immunochemical test (FIT)
  • At 55 you are offered a one off screening with flexible sigmoidoscopy
  • People aged 60-74 are sent a home FIT test to do every 2 years- if positive referred for colonoscopy
  • Patients with FAP, HNPCC or IBD are offered colonoscopy’s with biopsies at regular intervals to screen for bowel cancer
25
Q

Other incidents to use FIT

A
  • For patients who don’t meet the two week weight criteria
  • Over 50 with unexplained weight loss and no other symptoms
  • Under 60 with a change in bowel habit
26
Q

Treatment for different types of bowel cancer

A
  • Caecal, ascending or proximal transverse colon: Right hemicolectomy - Ileo-colic anastomosis
  • Distal transverse, descending colon: Left hemicolectomy - Colo-colon anastomosis
  • Sigmoid colon: High anterior resection - Colo-rectal anastomosis
  • Upper rectum: Anterior resection (TME)- Colo-rectal anastomosis
  • Low rectum: Anterior resection (Low TME) - Colo-rectal anastomosis (+/- Defunctioning stoma)
  • Anal verge: Abdomino-perineal excision of rectum- no anastomosis
27
Q

Duke’s classification of bowel cancer

A
  • A - confined to mucosa and part of the muscle of the bowel wall
  • B - extending through the muscle of the bowel wall
  • C - lymph node involvement
  • D - metastatic disease
28
Q

Cervical cancer

A

Highest rates in people aged 25-29. Divided into squamous cell carcinoma (80%) and adenocarcinoma (20%). Develop from cervical intraepithelial neoplasia (CIN) or adenocarcinoma in situ which becomes invasive.

29
Q

Cervical cancer: clinical features

A
  • May be detected during routine cervical cancer screening
  • Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
  • Vaginal discharge
  • Pelvic pain, Dyspareunia
30
Q

What PV examination findings would warrant urgent referral for colposcopy

A

abnormal appearance of cervix - ulceration, inflammation, bleeding, visible tumour

31
Q

What stains are used in colposcopy

A
  • acetic acid: causes abnormal cells to appear white
  • iodine solution: abnormal cells do not stain
32
Q

Cervical stains worse prognosis factors

A
  • C-myc overexpression
  • HIV positive
  • Infected with HPV 18
  • Number of cells in S phase
  • A polymorphism in the Gamma-glutamyl hydrolase enzyme decreases response to cisplatin
  • Poor prognosis is associated with adenocarcinoma, lymph node involvement, advanced clinical stage, large primary tumour and early recurrence. Relapse after 5 years is unusual.
33
Q

Cervical cancer risk factors

A
  • HPV serotypes 16 and 18: 18 associated with worse prognosis
  • Smoking
  • HIV: poorer prognosis
  • Early first intercourse, many sexual partners
  • High parity (lots of pregnancies)
  • Lower socioeconomic status
  • COCP
34
Q

Cervical cancer staging

A
  • HPV → CIN → Invasive cervical cancer
  • CIN 1: involvement of lower 1/3 of epithelium
  • CIN 2: involvement of lower 2/3 of epithelium
  • CIN 3: involvement of all layers of epithelium
  • 4a. spread to bladder or rectum
  • 4b. beyond
35
Q

Cervical cancer investigations

A
  • Colposcopy: acetic acid is applied to view the cervix, punch or loop biopsy is also obtained
  • Biopsy of lymph nodes
  • p21 staining on cervical biopsy would indicate HPV infection
  • Cystoscopy and sigmoidoscopy if suspicion of adjacent organ involvement
  • cervical smear
  • CT/MRI Thorax, Abdomen and Pelvis: for staging
36
Q

Cervical cancer screening

A
  • 25-49 years: 3-yearly screening
  • 50-64 years: 5-yearly screening
  • cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
  • In pregnancy its usually delayed till 3 months post partum
  • Women who have never been sexually active can opt out of screening
  • HPV vaccine (Cervarix) protects against HPV 16 and 18, and Gardasil protects against HPV 6, 11, 16 and 18
37
Q

Treatment for CIN and cervical caner staging

A

Treatment of CIN (cervical intra-epithelial neoplasia): large loop excision of transformation zone. Alternatively cryotherapy.

Cervical cancer staging: FIGO staging

38
Q

Cervical cancer: management of stage 1A tumours

A
  • Gold standard of treatment is hysterectomy +/- lymph node clearance
  • Nodal clearance for A2 tumours
  • For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
  • Close follow-up of these patients is advised
  • For A2 tumours, node evaluation must be performed
  • Radical trachelectomy is also an option for A2
39
Q

Cervical cancer: manageent of stage 1B tumours

A
  • For B1 tumours: radiotherapy with concurrent chemotherapy is advised
  • Radiotherapy may either be bachytherapy or external beam radiotherapy
  • Cisplatin is the commonly used chemotherapeutic agent
  • For B2 tumours: radical hysterectomy with pelvic lymph node dissection
40
Q

Cervical cancer stage II, III and IV

A

Stage II and III tumours: Radiation with concurrent chemotherapy. If hydronephrosis, nephrostomy should be considered

Stage IV: Radiation and/or chemotherapy is the treatment of choice. Palliative chemotherapy may be best option for stage IVB

Recurrent disease: If primary surgery treatment offer chemoradiation or radiotherapy. In primary radiation treatment, offer surgical theray

41
Q

Treatment of cervical cancer surgery

A
  • Local excision using loop diathermy is performed for CIN 2/3 confined to the visible ectocervix
  • Loop biopsy is performed for CIN 3 with disease extending into cervical canal
  • Simple hysterectomy is performed for micro-invasive disease
  • Stage IB or 2 cervical cancers: radical hysterectomy with pelvic lymphadenectomy or pelvic radiotherapy
42
Q

Treatment off cervical cancer: medical

A
  • Stage 2B and 3: pelvic radiotherapy and patients treated with curative intent typically receive chemoradiotherapy with cisplatin as a radiation sensitizer
  • Stage 4 and recurrent disease are treated with chemotherapy. Radiotherapy can be used to treat specific site of metastasis.
  • Chemotherapy alone has no role in the adjuvant treatment of cervical cancer
43
Q

Neutropenic sepsis criteria

A
  • Pyrexia > 38ºC on a single reading
  • Pyrexia > 37.5ºC on two readings over 1 hours
  • Rigor
  • Unexplained hypotension or tachycardia
  • In a patient with a neutrophil count <1.0 x 109/L
44
Q

Neutropenic sepsis: investigations and management

A
  • Bloods – FBC, biochemistry, coagulation screen
  • Septic screen – Blood culture, MSU, CXR +/- swabs
  • Antibiotics – as per local protocol but typically high dose intravenous antibiotics (tazocin/gentamicin)
  • If no response to antibiotics consider antifungal therapy and G-CSF
  • Aim to keep platelets >20 x 109/L
45
Q

Gastric cancer risk factors

A
  • Malignant neoplasm arising from the gastric epithelium
  • Most common histological subtype: Adenocarcinoma which can be divided into intestinal and diffuse
  • Presents at advanced stage with non specific symptoms: poor prognosis
46
Q

Gastric cancer - Histological classification Laurens classification

A
  • Intestinal type: Characterized by cohesive, gland-forming cells, associated with environmental factors such as H. pylori infection and dietary habits. Well differentiated tubular or glandular tumours
  • Diffuse type: Composed of poorly differentiated, discohesive cells, often with a genetic predisposition and a worse prognosis. Diffusely infiltrate the stomach wall
47
Q

Gastric cancer: other types of classification

A
  • Molecular: EBV positive, Microsatellite instability (MSI), Genomicaly stable (GS), Chromosome instability (CIN)
  • Anatomical location: Proximal (cardia) gastric cancer, Distal (non-cardia) gastric cancer
48
Q

Gastric cancer: other types of classification

A
  • Molecular: EBV positive, Microsatellite instability (MSI), Genomicaly stable (GS), Chromosome instability (CIN)
  • Anatomical location: Proximal (cardia) gastric cancer, Distal (non-cardia) gastric cancer
49
Q

Gastric cancer: clinical features

A
  • Dyspepsia or indigestion, dysphagia
  • Epigastric pain
  • Early satiety or postprandial fullness
  • Weight loss
  • Anaemia
  • Nausea and vomiting
  • Gastrointestinal bleeding (e.g., melena,haematemesis)
50
Q

Gastric cancer: signs of advanced disease

A
  • Advanced disease: palpable abdominal mass, ascites and supraclavicular lymphadenopathy (Virchow’s node), ancanthosis nigricans
  • hepatomegaly, jaundice, ascites due to liver mets
  • Diffuse cancer within the stomach wall: linitis plastica (leather bottle stomach which cant expand properly)

year 4 CDM 2 (39 decks)

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