Cancer Flashcards
risk factors breast cancer
high
- age
- hx atypical ductal hyperplasia, lobular carcinoma in situ
- BRCA1/2 mutations
- other genes
- Kleinfelter’s XXY in men
moderate
- hx ductal carcinoma in situ
- chest wall radiation for Hodgkin’s
- 2+ first-degree relatives
- high post-menopausal estrogen levels (often w/ obesity)
- mammogram shows dense breasts
low, but still elevated
- total lifetime estrogen exposure:
- – early menarche
- – late pregnancy
- – late menopause
- – nulliparous
- – no breast feeding
- – post-menopausal obesity
- alcohol
- sedentary
- benign proliferative breast disease
genes in breast cancer
- known pathogenic genes ~5-10% of cancers
typically
- young at dx
- Ashkenazi jew
- fhx early onset cancer
test if
- fhx any male breast cancer
- fhx ovarian, pancreatic, advanced prostate cancer
BRCA
BRCA
- tumor supressor
- LOF –> decreased DNA repair, increased genomic instability
- risk ~45-85% breast, ~40% ovarian
- but only makes up ~1 in 300 breast cancers
- high risk in Ashkenazi jewish, no other racial or ethnic association
tx considerations:
- bilateral prophylactic mastectomy
- contralateral “
- MRI surveillance
- PARPi
- endocrine tx if >3% 5yr risk
breast cancer screening
- majority of breast cancers dx’d by screening mammography
- USPSTF calculator for risk
- MRI screening for lifetime risk >20%
breast exam:
- palpable mass
- bloody nipple discharge
- nipple erosive rash
- peau d’orange (inflammatory bc)
- nipple retraction
dx breast cancer
- US
- mammogram
- MRI
- core needle biopsy –> typing, grade, receptor status, genetic status
most common subtype
most aggressive subtype
most common + best prognosis:
- Luminal A ER/PR+, Her2-
most aggressive:
- TNBC = ER/PR-, Her2-
most common histology: ductal ~80-85%
aggressive histologies:
- inflammatory (invasive ductal)
- lobular ~10-15%
tx breast cancer
surgery:
- no OS change w/ mastectomy vs lumpectomy/breast conservation
radiation:
- if breast conservation
- or if large tumor, skin/chest wall invasion, or positive nodes for conservation or mastectomy
chemo
- essentially always
targeted therapy, immunotherapy
- aggressive subtypes
- TNBC
- HER2+
- advanced disease
endocrine tx
- for ER+
- tamoxifen (SERM) - ER blocker
- aromatase inhibitors (-ozole) - estrogen production inhibitor
- SERDs (selective estrogen receptor degrader) such as fulvestrant for recurrent/metastatic
stage 4
- incurable
- lifelong
- QoL
- all to none of the above
tx considerations for bc survivors
- cardiac toxicity
- cognitive dysfunction
- fatigue
- lymphedema
- depression, PTSD, body image
- change in sex function
- sleep changes
- financial stress
- address tx long-term effects
- monitor for recurrence
- encourage lifestyle behaviors
ddx breast mass
- cancer
- abscess - post partum, piercing, mastitis, smoking
- fibroadenoma (20’s-30’s y/o)
- phyllodes tumor (30’s-40’s) - benign, but rapid enlargement
- cyst - pre and peri menopause
- fibrocystic change
- galactocele - milk retention cyst
- fat necrosis - trauma, surgical, radiation hx
- gynecomastia in men - meds, marijuana, alcohol
a&p breast mass
A
- full h&p
- fhx
- risk factor assessment
- duration
- assoc sx
- trauma
- fluctuation w/ cycle
P:: <30 y/o: US - cystic vs solid - aspiration if cyst - core needle biopsy if solid - watch and wait also acceptable if simple, non-painful, low index of suspicion
≥30 y/o: dx mammo w/ US
- same as above, aspiration, biopsy, expectant mgmt
prognosis ovarian cancer
5-yr OS ~50%
>90% if localized
~30 if disseminated
note that this is the highest mortality rate of any gyn cancer
histologic distribution ovarian cancer
serous 70%
endometriod ~10%
mutinous, clear cell, others
ovarian cancer risk fx
- age (+)
- fhx
- lifetime ovulatory cycles
- – early menses
- – nulliparity
- – older age at 1st preg >35
- – late menopause
- – no OCPs (~50% risk reduction if OCPs 5+ years)
- – no breastfeeding
- endometriosis (endometriod and clear cell tumors)
- smoking (mucinous tumors)
genes ovarian cancer
~20-25% known gene
~15% BRCA1/2
Lynch syndrome (HNPCC) - endometrioid or clear cell
presentation of ovarian cancer
- subtle
- pelvic discomfort - pulling, bloating, dull aching
- pelvic or abd pain
- early satiety
- change in bowel habits
- urinary urgency or frequency
- fatigue
ovarian tumor markers
- CA-125
- – pre-menopause normal <200
- – post-menopause <35
- HE4
- BhCG
- LDH
- AFP
- inhibin
psammoma bodies
round collection of calcium
present in ~25% of serous tumors
cervical cancer risk factors
- HPV: *16, 18 ~70%, E6 oncoprotein inhibits p53
- – others: 31,33,45,52,58,etc.
- smoking
- +parity
- OCPs
- early sexual debut
- many sexual partners
- h/o STIs
- immunosuppression
ACS screening guidelines cervical cancer
<25 no screening (previous q3 years from 21)
25-65 HPV screen q5 years, or cytology q3 years
presentation of cervical cancer
(advanced)
- vaginal bleeding
- discharge
- pelvic pain
- difficulty urinating
- constipation
- flank pain/renal failure d/t hydronephrosis
dx cervical cancer
- cervical cytology ± HPV test
- colposcopy ± biopsy
- cone biopsy
imaging:
- CXR
- CT
- PET/CT
- MRI
labs:
- CBC, CMP
tx cervical cancer
microinvasive/early
- hysterectomy
- pelvic lympadenectomy
local advanced
- chemo + radiation
metastatic
- chemo
- localized tx - surgery + radiation
surveillance cervical cancer
~7-36 mo median recurrence at:
- vaginal apex, central pelvis 25-55%
- pelvic sidewall
- distant
- f/u q6mo x2yr, then q6-12mo
endometrial cancer prognosis
most common gyn cancer
~80% 5-yr OS
endometrial cancer risk factors
- total lifetime estrogen
- tamoxifen
- diabetes
- PCOS
- Lynch syndrome (HNPCC)
- Cowden syndrome
endometrial cancer presentation
- vaginal bleeding, postmenopausal bleeding >90%
- abnormal PAP
- incidental - thickened lining on US
endometrial cancer dx
postmenopause: thickened lining on TVUS
premenopausal: not as helpful
endometrial biopsy >90%
endometrial cancer tx
most often TAH-BSO w/ bilateral lymph node assessment
fertility sparing options such as progestin, IUD possible if women meet very specific criteria
adjuvants depending on stage
testicular cancer incidence and prognosis
rare, ~1% mostly young men 15-40 (ddx testis mass >50 yr ~ lymphoma) >95% germ cell tumors -- seminoma ~40% >90% cure rate, 5yr OS 95%
aggressive subsets:
- anaplastic seminoma
- embryonal carcinoma
testicular cancer risk factors
cryptorchidism (in contralateral testis) XXY fhx pmhx intratubular germ cell neoplasia - precursor lesion
testicular cancer presentation
- testicular mass
- hard, non-tender
- normal spermatic cord, intact cremaster
- possible cryptorchidism
pertienent negatives:
- no pain
- otherwise well
- no trauma
- no gross hematuria
- no dysruia
- no sexual risk factors (necessarily)
- no weight loss, sweats, fevers
dx testicular mass
- scrotal ultrasound
- tumor markers
- AFP
- HCG
- LDH (non-specific)
- generally not elevated in seminoma (AFP never elevated), but can be followed to track tx response - testicular pathology following orchiectomy
- staging CTs to determine metastasis, f/u tumor markers
tx testicular mass
radical orchiectomy via inguinal canal
possible prosthesis placed
classic seminoma
~35% testicular cancers
± hCG, –AFP
good prognosis
20-30 y/o
generally highly responsive to chemo (as with other seminomas) though generally not needed except as a “just in case” approach
anaplastic seminoma
aggressive subset, high metastatic potential
rare
± hCG, –AFP
generally highly responsive to chemo (as with other seminomas)
- cisplatin
spermatohytic seminoma
not aggressive
age >50
± hCG, –AFP
embryona carcinoma
aggressive subset, highly malignant often spermatic cord invasion common feature of mixed germ cell tumors 20-30 y/o usually \+AFP, +HCG, usually
yolk sac tumor
common feature of mixed germ cell tumors
most common form in children
+AFP
shiller-duval bodies (resemble a glomerulus)
choriocarcinoma
aggressive, commonly metastasizes to lung and brain
early metastasis –> potentially small primary tumor
+HCG
teratoma
all 3 germ layers
feature of mixed tumors ~50%
may be pure form in children
usually normal tumor markers, ±AFP
RPLND
retroperitoneal lymph node dissection may be indicated in metastatic testicular cancer challenging, major operation may cause retrograde/anejaculation some iterations nerve sparing
risk fx prostate cancer
- age >70 (most men over 70 will have some amount of prostate cancer)
- fhx
- germline mutations ~8%
- race - +73% black; also a prognostic factor
- smoking
- obesity
PSA
- secreted into semen by epithelial cells of prostate
- liquifies semen to allow sperm to swim, dissolve cervical mucus
- screening and monitoring, not dx
elevated in:
- prostatitis
- BPH
- cancer
tends to detect cancer ~10 yr prior to sx, which has drastically cut death rate but led to overdx and tx
Gleason score
strong predictor of prostate cx px
microscopic appearance of gland architecture on biopsy
score = (1-5 rank of most prevalent pattern) + (2nd most prevalent)
Gleason 3+3=6 prostate cancer
- indolent, NEVER metastasizes
- doesn’t seem to turn into higher grade (unclear)
- unclear if associated with other types of prostate cancer elsewhere
- does not require tx
- “cancer”?
mgmt localized prostate cancer
- watchful waiting, life expectancy ≤10yr
- monitor PSA and symptoms
- no expectancy to intervene w/ curative intent
- active surveillance very low to favorable risk
- monitor PSA and repeat biopsy
- expectancy to intervene w/ curative intent
- focal tx
- lumpectomy
- heat/cold local destruction (lack of long term data)
- radical prostatectomy
- gold standard
- prostate, seminal vesicles, LNs
- technically demanding, usually robotic
- sfx: urinary incontinence (usually transient and/or mild), ED (majority, permanent)
- radiation tx ± androgen deprevation
- gold standard
- more favorable sfx than surgery
metastatic prostate cx
- LN and bones
- PSA > 20 usually
sx:
- possibly asymptomatic still
- bone pain
- ureter obstruction
tx:
- systemic disease –> systemic tx
- androgen deprivation (castrate sensitive; usually most are for 2-3 yr)
- if castrate resistant: chemo, liquid radiation, olaparib, sipuleucel T (cell immune tx), pembrolizumab
