Cancer Flashcards
Learning objectives
Answer
Define basal cell carcinoma
• COMMONEST form of skin malignancy, also known as a rodent ulcer
Explain the aetiology / risk factors of basal cell carcinoma
- MAIN RISK FACTOR: prolonged sun exposure or UV radiation
- Seen in Gorlin’s syndrome
Other risk factors:
o Photosensitising pitch
o Tar
o Arsenic
Summarise the epidemiology of basal cell carcinoma
- COMMON in those with FAIR SKIN
- Common in areas of high sunlight exposure
- Common in the elderly
- Rare before the age of 40 yrs
- Lifetime risk in Caucasians = 1 in 3
Recognise the presenting symptoms of basal cell carcinoma
• A chronic slowly progressive skin lesion • Usually found on the: o FACE o Scalp o Ears o Trunk
Recognise the signs of basal cell carcinoma on physical examination
Nodulo-ulcerative (MOST COMMON)
o Small glistening translucent skin over a coloured papule
o Slowly enlarges
o Central ulcer with raised pearly edges
o Fine telangiectasia over the tumour surface
o Cystic change in larger lesions
Morphoeic
o Expanding
o Yellow/white waxy plaque with an ill-defined edge
o More aggressive than nodulo-ulcerative
Superficial
o Most often on trunk
o Multiple pink/brown scaly plaques with a fine edge expanding slowly
Pigmented
o Specks of brown or black pigment may be present in any BCC
Identify appropriate investigations for basal cell carcinoma and interpret the results
- Biopsy is RARELY necessary
* Diagnosis is mainly on clinical suspicion
Define bladder cancer
• Malignancy of bladder cells
o Most bladder cancers are transitional cell carcinomas
o RARELY, bladder cancers may be squamous cell carcinomas associated with chronic inflammation (e.g. schistosomiasis)
Explain the aetiology / risk factors of bladder cancer
• UNKNOWN • Risk Factors o Smoking o Dye stuffs (naphthylamines and benzidine) o Cyclophosphamide treatment o Pelvic irradiation o Chronic UTIs o Schistosomiasis
Summarise the epidemiology of bladder cancer
- 2% of cancers
- 2nd most common cancer of the genitourinary tract
- 2-3 x more common in MALES
- Peak incidence: 50-70 yrs
Recognise the presenting symptoms of bladder cancer
• Painless macroscopic haematuria • Irritative/storage symptoms o Frequency o Urgency o Nocturia • Recurrent UTIs • Rarely: ureteral obstruction
Recognise the signs of bladder cancer on physical examination
- Often NO SIGNS
* Bimanual examination may be performed as part of disease staging
Identify appropriate investigations for bladder cancer and interpret the results
- Cystoscopy - allows visualisation, biopsy or removal
- Ultrasound
- Intravenous urography
- CT/MRI for staging
Define breast cancer
• Malignancy of breast tissue
o Most common type: invasive ductal carcinoma
Explain the aetiology / risk factors of breast cancer
- Genetics (e.g. BRCA-1 and BRCA-2 genes)
- Environmental factors
Risk Factors o Age o Prolonged exposure to oestrogen • Nulliparity (not having kids) • Early menarche • Late menopause • Obesity • COCP • HRT o Family history of breast cancer
Summarise the epidemiology of breast cancer
- Most common cancer in women (1/9 women in the UK)
* Peak incidence: 40-70 yrs
Recognise the presenting symptoms of breast cancer
• Breast lump (usually painless) • Changes in breast shape • Nipple discharge (may be bloody) • Axillary lump • Symptoms of malignancy: o Weight loss o Bone pain o Paraneoplastic syndromes
Recognise the signs of breast cancer on physical examination
• Breast lump o Firm o Irregular o Fixed to surrounding structures • Peau d'orange • Skin tethering • Fixed to chest wall • Skin ulceration • Nipple inversion
• Paget’s disease of the nipple - eczema-like hardening of the skin on the nipple
o Usually caused by ductal carcinoma in situ infiltrating the nipple
Identify appropriate investigations for breast cancer and interpret the results
TRIPLE ASSESSMENT o Clinical examination o Imaging: • Ultrasound (< 35 yrs) OR • Mammogram (> 35 yrs) o Tissue Diagnosis: • Fine Needle Aspiration OR • Core Biopsy
Sentinel Lymph Node Biopsy
o A radioactive tracer is injected into the tumour and a scan identifies the sentinel lymph node
o This node is then biopsied to check the extend of spread
Staging
o CXR
o Liver ultrasound
o CT (brain/thorax)
Bloods: FBC, U&Es, calcium, bone profile, LFTs, ESR
Define central nervous system (CNS) tumours
- Tumours of the central nervous system.
- NOTE: brain tumours cannot be truly differentiated into benign and malignant because supposedly ‘benign’ tumours can cause significant morbidity and mortality
Instead they are differentiated into:
High-Grade = a tumour that grows rapidly and aggressively
• Glioma and glioblastoma multiforme
• Primary cerebral lymphoma
• Medulloblastoma
Low-Grade = a tumour that grows slowly and may or may not be successfully treated • Meningioma • Acoustic neuroma • Neurofibroma • Pituitary tumour • Craniopharyngeoma • Pineal tumour
Brain metastases commonly arise from: • Lung • Breast • Stomach • Prostate • Thyroid • Colorectal
Explain the aetiology / risk factors of central nervous system (CNS) tumours
• Can arise from any of the cells in the CNS (e.g. glial cells, ependymal cells, oligodendrocytes)
• Risk Factors
o Ionising radiation
o Immunosuppression (e.g. HIV)
o Inherited syndromes (e.g. neurofibromatosis, tuberous sclerosis)
Summarise the epidemiology of central nervous system (CNS) tumours
- Primary brain tumours = 2% of tumours diagnosed in the UK
- AIDS patients have an increased risk of developing CNS tumours
- Can develop at any age but are more common between 50-70 yrs
Recognise the presenting symptoms & signs of central nervous system (CNS) tumours
- Presentation depends on the size and location of the tumour
- Headache (worse in the morning and when lying down)
- Nausea and vomiting
- Seizures
- Progressive focal neurological deficits
- Cognitive and behavioural symptoms
- Papilloedema
Identify appropriate investigations for central nervous system (CNS) tumours and interpret the results
- Bloods - check CRP/ESR to eliminate other causes (e.g. temporal arteritis)
- CT/MRI
- Biopsy and tumour removal
- Magnetic resonance angiography - define changing size and blood supply of the tumour
- PET
- NOTE: distant metastases are RARE with primary CNS tumours
Define cholangiocarcinoma
• Primary adenocarcinoma of the biliary tree
Explain the aetiology / risk factors of cholangiocarcinoma
• UNKNOWN
• Risk Factors
o Ulcerative colitis + primary sclerosing cholangitis
o Choledochal cyst (congenital conditions involving cystic dilatations of bile ducts)
o Caroli disease (rare genetic condition in which you get dilatation of intrahepatic bile ducts)
o Parasitic infection of biliary tract
Summarise the epidemiology of cholangiocarcinoma
- VERY RARE
* More common in the developing world due to the increased prevalence of parasitic infections
Recognise the presenting symptoms of cholangiocarcinoma
Obstructive jaundice symptoms o Yellow sclera o Pale stools o Dark urine o Pruritus
Abdominal pain or fullness
Systemic symptoms of malignancy: weight loss, malaise, anorexia
Recognise the signs of cholangiocarcinoma on physical examination
• Jaundice • Palpable gallbladder o NOTE: Courvoisier's Law - in the presence of jaundice, a palpable gallbladder (that is non-tender) is unlikely to be due to gallstones (i.e. cancer of the pancreas or biliary tree is more likely) • Epigastric/RUQ mass • There may be hepatomegaly
Identify appropriate investigations for cholangiocarcinoma and interpret the results
Bloods o FBC o U&Es o LFTs (high ALP + GGT) o Clotting screen o Tumour markers • CA19-9 is a marker of pancreatic cancer and cholangiocarcinoma
Endoscopy
o ERCP will allow bile cytology and tumour biopsy
Ultrasound
CT, MRI, Bone Scan - for staging
Define colorectal carcinoma
• Malignant adenocarcinoma of the large bowel o Distribution: • 60% - rectum and sigmoid • 30% - descending colon • 10% - rest of colon
Explain the aetiology / risk factors of colorectal carcinoma
• Environmental and genetic • There is a sequence of genetic changes that go from normal bowel epithelium to cancer (e.g. APC, K-Ras) • Risk Factors o Western diet (e.g. red meat, alcohol) o Colorectal polyps o Previous colorectal cancer o Family history o IBD
Summarise the epidemiology of colorectal carcinoma
- SECOND MOST COMMON cause of cancer death in the West
- UK: 20,000 deaths per year
- Average age of diagnosis: 60-65 yrs
Recognise the presenting symptoms of colorectal carcinoma
• Depends on the size and location of the tumour
Left-Sided Colon and Rectum
o Change in bowel habit
o Rectal bleeding (blood or mucus mixed with the stools)
o Tenesmus (due to a space-occupying tumour in the rectum)
Right-Sided Colon o Presents later o Anaemia symptoms (lethargy) o Weight loss o Non-specific malaise o Lower abdominal pain (rare)
IMPORTANT: 20% of tumours will present as an EMERGENCY with pain and distension due to:
o Large bowel obstruction
o Haemorrhage or peritonitis due to perforation
Recognise the signs of colorectal carcinoma on physical examination
- Anaemia
- Abdominal mass
If metastatic:
o Hepatomegaly
o Ascites (shifting dullness)
• Low-lying rectal tumours may be palpable on DRE
Identify appropriate investigations for colorectal carcinoma and interpret the results
Bloods
o FBC - anaemia
o LFTs
o Tumour markers (CEA)
Stools
o FOBT - used as a screening test
Endoscopy
o Sigmoidoscopy
o Colonoscopy
o This can be used to biopsy the tumour
Double-Contrast Barium Enema
o May show ‘apple core’ strictures
Contrast CT
o For staging (Duke’s staging)
Define deep vein thrombosis (DVT)
• Formation of a thrombus within the deep veins (most commonly in the calf or thigh)
Explain the aetiology / risk factors of deep vein thrombosis (DVT)
• Deep veins in the legs are more prone to blood stasis, hence clots are more likely to form (look up Virchow’s triad)
Risk Factors o COCP o Post-surgery o Prolonged immobility o Obesity o Pregnancy o Dehydration o Smoking o Polycythaemia o Thrombophilia (e.g. protein C deficiency) o Malignancy
Summarise the epidemiology of deep vein thrombosis (DVT)
- VERY COMMON
* Especially in hospitalised patients
Recognise the presenting symptoms of deep vein thrombosis (DVT)
- Swollen limb
* May be painless
Recognise the signs of deep vein thrombosis (DVT) on physical examination
Examination of the Leg
o Local erythema, warmth and swelling
o Measure the leg circumference
o Varicosities (swollen/tortuous vessels)
o Skin colour changes
o NOTE: Homan’s Sign - forced passive dorsiflexion of the ankle causes deep calf pain
Risk is stratified using the WELLS CRITERIA (NOTE: this is different from the PE Wells criteria)
o Score 2 or more = high risk
Examine for PE
o Check respiratory rate, pulse oximetry and pulse rate
Identify appropriate investigations for deep vein thrombosis (DVT) and interpret the results
Doppler Ultrasound - GOLD STANDARD
Impedance Plethysmography - changes in blood volume results in changes of electrical resistance
Bloods
o D-dimer: can be used as a negative predictor
o Thrombophilia screen if indicated
If PE suspected
o ECG
o CXR
o ABG
Generate a management plan for deep vein thrombosis (DVT)
ANTICOAGULATION
o Heparin whilst waiting for warfarin to increase INR to the target range of 2-3
o DVTs that do NOT extend above the knee may be observed and anticoagulated for 3 months
o DVTs extending beyond the knee require anticoagulation for 6 months
o Recurrent DVTs require long-term warfarin
IVC Filter
o May be used if anticoagulation is contraindicated and there is a risk of embolisation
Prevention
o Graduated compression stockings
o Mobilisation
o Prophylactic heparin (if high risk e.g. hospitalised patients)
Identify the possible complications of deep vein thrombosis (DVT) and its management
- PE
- Venous infarction (phlegmasia cerulea dolens)
- Thrombophlebitis (results from recurrent DVT)
- Chronic venous insufficiency
Summarise the prognosis for patients with deep vein thrombosis (DVT)
- Depends on extent of DVT
- Below-knee DVTs have a GOOD prognosis
- Proximal DVTs have a greater risk of embolisation
Define gastric cancer
• Cancer of the stomach. Most commonly adenocarcinoma
Rarer causes of gastric cancer:
• Lymphoma
• Leiomyosarcoma
• Stromal tumours
Explain the aetiology / risk factors of gastric cancer
- UNKNOWN
- Environment and genetics
Risk Factors o Smoked and processed foods o Smoking o Alcohol o Helicobacter pylori infection o Atrophic gastritis o Pernicious anaemia o Partial gastrectomy o Gastric polyps
Summarise the epidemiology of gastric cancer
- COMMON cause of cancer death worldwide
- Highest incidence in JAPAN (and Asia in general)
- 6th most common cancer in the UK
- Usual age of presentation: > 50 yrs
Recognise the presenting symptoms of gastric cancer
- Often asymptomatic early
- Early satiety
- Epigastric discomfort
- Systemic symptoms: weight loss, anorexia, nausea/vomiting
- Dysphagia (in tumours of the gastric cardia)
- Symptoms of metastases (e.g. ascites, jaundice)
Recognise the signs of gastric cancer on physical examination
- Epigastric mass
- Abdominal tenderness
- Ascites
- Signs of anaemia
- Virchow’s Node (aka Troisier’s sign)
- Sister Mary Joseph’s Nodule (metastatic node on the umbilicus)
- Krukenberg’s Tumour (ovarian metastases)
Identify appropriate investigations for gastric cancer and interpret the results
- Upper GI endoscopy
- Bloods - FBC (check for anaemia), LFTs
- CT/MRI - for staging
- Endoscopic USS - assess depth of gastric invasion and lymph node involvement
Define hepatocellular carcinoma
• Primary malignancy of the liver parenchyma
Explain the aetiology / risk factors of hepatocellular carcinoma
Associated with:
Chronic liver damage
• Alcoholic liver disease
• Hepatitis C
• Autoimmune disease
Metabolic disease
• E.g. haemochromatosis
Aflatoxins
• E.g. cereals contaminated with fungi
Summarise the epidemiology of hepatocellular carcinoma
- COMMON
- 1-2% of all malignancies
- LESS common than liver metastases
- High incidence in regions where hepatitis B and C are endemic
Recognise the presenting symptoms of hepatocellular carcinoma
Symptoms of Malignancy
o Malaise
o Weight loss
o Loss of appetite
History of Exposure to Carcinogens
o High alcohol intake
o Hepatitis B or C (e.g. sexual activity, IV drug use)
o Aflatoxins
Abdominal distention
Jaundice
Recognise the signs of hepatocellular carcinoma on physical examination
Signs of Malignancy
o Cachexia
o Lymphadenopathy
- Hepatomegaly (may be nodular)
- Jaundice
- Ascites
- Bruit over the liver
Identify appropriate investigations for hepatocellular carcinoma and interpret the results
Bloods o FBC o ESR o LFTs o Clotting o a-fetoprotein - tumour marker for liver cancer o Hepatitis serology
Imaging
o Abdominal US
o CT/MRI - GOLD STANDARD for staging
Histology/Cytology
o Ascitic tap my be sent for cytological analysis
Staging
o CT scan (chest/abdo/pelvis)
Define ALL
• Malignancy of the bone marrow and blood characterised by the proliferation of lymphoblasts (primitive lymphoid cells)
Explain the aetiology / risk factors of ALL
- Lymphoblasts undergo malignancy transformation and proliferation
- This leads to the replacement of normal marrow elements, leading to bone marrow failure and infiltration into other tissues
Risk Factors: o Environmental (radiation, viruses) o Genetic (Down's syndrome, Neurofibromatosis type 1, Fanconi's anaemia, xeroderma pigmentosum)
Summarise the epidemiology of ALL
- MOST COMMON malignancy of CHILDHOOD
- Peak incidence: 2-5 yrs old
- There is a second peak in incidence in the elderly
- Annual UK incidence: 1/70,000
Recognise the presenting symptoms of ALL
Symptoms of Bone Marrow Failure:
o Anaemia (fatigue, dyspnoea)
o Bleeding (spontaneous bruising, bleeding gums, menorrhagia)
o Opportunistic infections
Symptoms of Organ Infiltration: o Tender bones o Enlarged lymph nodes o Mediastinal compression o Meningeal involvement (headache, visual disturbances, nausea)
Recognise the signs of ALL on physical examination
Signs of Bone Marrow Failure: o Pallor o Bruising o Bleeding o Infection
Signs of Organ Infiltration: o Lymphadenopathy o Hepatosplenomegaly o Cranial nerve palsies o Retinal haemorrhage o Papilloedema on fundoscopy o Leukaemic infiltration of the anterior chamber of the eye o Testicular swelling
Identify appropriate investigations for ALL and interpret the results
Bloods o FBC - normochromic normocytic anaemia, low platelets, variable WCC o High uric acid o High LDH o Clotting screen
Blood Film
o Abundant lymphoblasts
Bone Marrow Aspirate or Trephine Biopsy
o Hypercellular with > 20% lymphoblasts
Immunophenotyping - using antibodies to recognise cell surface antigens
Cytogenetic - karyotyping to look for chromosomal abnormalities or translocations
Cytochemistry
Lumbar Puncture - check for CNS involvement
CXR - may show mediastinal lymphadenopathy, lytic bone lesions
Bone Radiographs - mottled appearance with punched out lesions due to leukaemic infiltration
Define AML
• Malignancy of primitive myeloid lineage white blood cells (myeloblasts) with proliferation in the bone marrow and blood
o Classified using the FAB (French-American-British) System into EIGHT morphological variants
Explain the aetiology / risk factors of AML
- Myeloblasts undergo malignant transformation and proliferation
- This leads to replacement of normal marrow and bone marrow failure
Summarise the epidemiology of AML
- MOST COMMON acute leukaemia in ADULTS
* Incidence INCREASES with age