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SFM5 > Cancer > Flashcards

Cancer Flashcards

1
Q

risk factors breast cancer

A

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
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2
Q

genes in breast cancer

A
  • 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

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3
Q

BRCA

A
  • 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
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4
Q

breast cancer screening

A
  • 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
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5
Q

dx breast cancer

A
  • US
  • mammogram
  • MRI
  • core needle biopsy –> typing, grade, receptor status, genetic status
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6
Q

most common subtype

most aggressive subtype

A

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%
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7
Q

tx breast cancer

A

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
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8
Q

tx considerations for bc survivors

A
  • 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
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9
Q

ddx breast mass

A
  • 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
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10
Q

a&p breast mass

A

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

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11
Q

prognosis ovarian cancer

A

5-yr OS ~50%
>90% if localized
~30 if disseminated

note that this is the highest mortality rate of any gyn cancer

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12
Q

histologic distribution ovarian cancer

A

serous 70%
endometriod ~10%
mutinous, clear cell, others

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13
Q

ovarian cancer risk fx

A
  • 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)
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14
Q

genes ovarian cancer

A

~20-25% known gene
~15% BRCA1/2
Lynch syndrome (HNPCC) - endometrioid or clear cell

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15
Q

presentation of ovarian cancer

A
  • subtle
  • pelvic discomfort - pulling, bloating, dull aching
  • pelvic or abd pain
  • early satiety
  • change in bowel habits
  • urinary urgency or frequency
  • fatigue
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16
Q

ovarian tumor markers

A
  • CA-125
  • – pre-menopause normal <200
  • – post-menopause <35
  • HE4
  • BhCG
  • LDH
  • AFP
  • inhibin
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17
Q

psammoma bodies

A

round collection of calcium

present in ~25% of serous tumors

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18
Q

cervical cancer risk factors

A
  • 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
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19
Q

ACS screening guidelines cervical cancer

A

<25 no screening (previous q3 years from 21)

25-65 HPV screen q5 years, or cytology q3 years

20
Q

presentation of cervical cancer

A

(advanced)

  • vaginal bleeding
  • discharge
  • pelvic pain
  • difficulty urinating
  • constipation
  • flank pain/renal failure d/t hydronephrosis
21
Q

dx cervical cancer

A
  • cervical cytology ± HPV test
  • colposcopy ± biopsy
  • cone biopsy

imaging:

  • CXR
  • CT
  • PET/CT
  • MRI

labs:
- CBC, CMP

22
Q

tx cervical cancer

A

microinvasive/early

  • hysterectomy
  • pelvic lympadenectomy

local advanced
- chemo + radiation

metastatic

  • chemo
  • localized tx - surgery + radiation
23
Q

surveillance cervical cancer

A

~7-36 mo median recurrence at:

  • vaginal apex, central pelvis 25-55%
  • pelvic sidewall
  • distant
  • f/u q6mo x2yr, then q6-12mo
24
Q

endometrial cancer prognosis

A

most common gyn cancer

~80% 5-yr OS

25
Q

endometrial cancer risk factors

A
  • total lifetime estrogen
  • tamoxifen
  • diabetes
  • PCOS
  • Lynch syndrome (HNPCC)
  • Cowden syndrome
26
Q

endometrial cancer presentation

A
  • vaginal bleeding, postmenopausal bleeding >90%
  • abnormal PAP
  • incidental - thickened lining on US
27
Q

endometrial cancer dx

A

postmenopause: thickened lining on TVUS
premenopausal: not as helpful

endometrial biopsy >90%

28
Q

endometrial cancer tx

A

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

29
Q

testicular cancer incidence and prognosis

A 
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
30
Q

testicular cancer risk factors

A 
cryptorchidism (in contralateral testis)
XXY
fhx
pmhx
intratubular germ cell neoplasia - precursor lesion
31
Q

testicular cancer presentation

A
  • 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
32
Q

dx testicular mass

A
  1. scrotal ultrasound
  2. tumor markers
    - AFP
    - HCG
    - LDH (non-specific)
    - generally not elevated in seminoma (AFP never elevated), but can be followed to track tx response
  3. testicular pathology following orchiectomy
  4. staging CTs to determine metastasis, f/u tumor markers
33
Q

tx testicular mass

A

radical orchiectomy via inguinal canal

possible prosthesis placed

34
Q

classic seminoma

A

~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

35
Q

anaplastic seminoma

A

aggressive subset, high metastatic potential
rare
± hCG, –AFP

generally highly responsive to chemo (as with other seminomas)
- cisplatin

36
Q

spermatohytic seminoma

A

not aggressive
age >50
± hCG, –AFP

37
Q

embryona carcinoma

A 
aggressive subset, highly malignant
often spermatic cord invasion
common feature of mixed germ cell tumors
20-30 y/o usually
\+AFP, +HCG, usually
38
Q

yolk sac tumor

A

common feature of mixed germ cell tumors
most common form in children
+AFP
shiller-duval bodies (resemble a glomerulus)

39
Q

choriocarcinoma

A

aggressive, commonly metastasizes to lung and brain
early metastasis –> potentially small primary tumor
+HCG

40
Q

teratoma

A

all 3 germ layers
feature of mixed tumors ~50%
may be pure form in children
usually normal tumor markers, ±AFP

41
Q

RPLND

A 
retroperitoneal lymph node dissection
may be indicated in metastatic testicular cancer
challenging, major operation
may cause retrograde/anejaculation
some iterations nerve sparing
42
Q

risk fx prostate cancer

A
  • 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
43
Q

PSA

A
  • 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

44
Q

Gleason score

A

strong predictor of prostate cx px
microscopic appearance of gland architecture on biopsy

score = (1-5 rank of most prevalent pattern) + (2nd most prevalent)

45
Q

Gleason 3+3=6 prostate cancer

A
  • 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”?
46
Q

mgmt localized prostate cancer

A
  • 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
47
Q

metastatic prostate cx

A
  • 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

SFM5 (14 decks)

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