Cancer Flashcards
1
Q
Colorectal cancer: risk factors
A
- Family history of bowel cancer
- Familial adenomatous polyposis(FAP)
- Hereditary nonpolyposis colorectal cancer(HNPCC), also known asLynch syndrome
- Inflammatory bowel disease (Crohn’s or ulcerative colitis)
- Increased age
- Diet (high in red and processed meat and low in fibre)
- Obesity and sedentary lifestyle
- Smoking
- Alcohol
2
Q
FAP
A
autosomal dominant condition causing malfunctioning of tumour suppressor gene resulting in polyps in the large intestine.
3
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
4
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
5
Q
Colorectal cancer investigations
A
- bedside:- full set of obs
- bloods:- FBC to look for anaemia- U+Es for baseline- LFTs to look for liver mets- CEA for baseline
- imaging:- colonoscopy is diagnostic, contrast CT chest abdo pelvis for staging
- special tests:- biopsy taken during colonoscopy
6
Q
Colorectal cancer management
A
- conservative:- MDT involvement esp post op (dietician, stoma nurse, physio)
- medical:- chemo- radiotherapy
- surgical:- hemi or total colectomy
7
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
8
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.
9
Q
Hartmanns procedure
A
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.
10
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
- Requirement for a stoma
- Failure to remove the tumour
- Change in bowel habit
- Venous thromboembolism (DVT and PE)
- Incisional hernias
- Intra-abdominal adhesions
11
Q
Colorectal cancer: follow up
A
- Serum carcinoembryonic antigen (CEA)
- CT thorax, abdomen and pelvis
- Normally over 3 years
12
Q
Screening for bowel cancer
A
- The Faecal immunochemical test (FIT)
- 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 at regular intervals to screen for bowel cancer
13
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
14
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
15
Q
Types of lung cancer
A
- Small cell lung cancer (20%)
- Non small cell lung cancer (80%)
- Non small cell lung cancer can be split into: Adenocarcinoma (40%), squamous cell carcinoma (20%), Large cell carcinoma (10%)
16
Q
Presentation of lung cancer
A
- Shortness of breath
- Cough
- Haemoptysis(coughing up blood)
- Finger clubbing
- Wheeze or stridor
- Recurrent pneumonia
- Weight loss
- Hoarseness and dysphagia
- Lymphadenopathy – oftensupraclavicularnodes are the first to be found on examination
17
Q
Paraneoplastic syndrome
A
- Hypercalcaemia: Often due to production of parathyroid hormone-related peptide (PTHrP).
- Cushing’s syndrome: Due to ectopic adrenocorticotropic hormone (ACTH) production.
- SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion): Leading tohyponatraemia
- Lambert-Eaton myasthenic syndrome (LEMS): A neuromuscular disorder caused by antibodies directed against voltage-gated calcium channels in the presynaptic nerve terminals.
- Clubbing: A finger deformity seen in certain chronic diseases, including lung cancer
18
Q
Lung cancer investigations
A
bedside: full set of obs
bloods:
- FBC to look for anaemia
- U+Es for baseline
- LFTs to look for liver mets
- LDH may be raised in SCLC
- calcium may be raised in squamous NSCLC
imaging:
- CXR
- contrast enhanced CT chest abdo pelvis for staging
- PET CT for metastases
- bronchoscopy with endobronchial ultrasound
special tests:
- sputum cytology
- biopsy via bronchoscopy, needle or surgery
- lung function tests
19
Q
Management of lung cancer
A
- conservative:- smoking cessation
- medical:- radiotherapy for stages 1-3- chemotherapy as adjunct to surgery/ radiotherapy
- surgical:- lobectomy (1st line for stages 1-2)
20
Q
Extrapulmonary manifestations of lung cancer
A
- Small cell lung cancer: can cause paraneoplastic syndrome
- Recurrent laryngeal nerve palsy: hoarse voice due to a tumour pressing on the nerve
- Phrenic nerve palsy: diaphragm weakness causing SOB
- Horner’s syndromeis a triad of partial ptosis, anhidrosis andmiosis. It can be caused by aPancoast tumour(tumour in thepulmonary apex) pressing on thesympathetic ganglion.
- Syndrome of inappropriate ADH(SIADH) can be caused byectopic ADHsecreted by asmall cell lung cancer. It presents withhyponatraemia.
- Cushing’s syndromecan be caused byectopic ACTHsecretion by asmall cell lung cancer.
- Hypercalcaemiacan be caused byectopic parathyroid hormonesecreted by asquamous cell carcinoma.
21
Q
Lambert easton myasthenic syndrome
A
- Caused by antibodies produced by the immune system against small cell lung cancer cells
- Causes weakness in proximal muscles, diplopia, ptosis, slurred speech and dysphagia
- Autonomic dysfunction: dry mouth, blurred vision, impotence and dizziness
22
Q
Referral criteria for lung cancer (2 week wait): patients over 40 with
A
- Clubbing
- Lymphadenopathy(supraclavicularor persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
- Consider a CXR in patients >40 who have two or more unexplained symptoms in patients that have never smoked or one or more unexplained symptoms in patient that have smoked
- Unexplained symptoms: cough, SOB, fatigue, chest pain, weight loss, loss of appetitie
23
Q
Investigations for lung cancer
A
- CXR: first line, show hilar enlargement, peripheral opacity, pleural effusion and collapse
- Staging CT of chest, abdomen and pelvis: assesses stage, lymph node involvement and metastasis
- PET-CT
- Bronchoscopy with endobronchial ultrasound (EBUS): detailed assessment of tumour and US guided biopsy
- Histological diagnosis: either bronchoscopy or percutaneous biopsy
24
Q
Lung cancer treatment options
A
- MDT meeting discussion
- Surgery: first line in non-small cell lung cancer isolated to a single area
- Radiotherapy: non small cell lung cancer caught. Stages I-III not suitable for surgery aiming for cure
- Chemotherapy: palliative in non-small cell lung cancer or in addition to surgery or radiotherapy (adjuvant chemotherapy). Used in stage III-IV (paliative)
- Treatment for small cell lung cancer: chemotherapy and radiotherapy (prognosis is worse)
- Endobronchial treatment with stents and debulking: palliative in bronchial obstruction
25
Q
Treatment for SCLC
A
- Surgery: only considered in stage I-II
- Majority treatment with chemotherapy and radiotherapy
- In relapses SCLC consider further chemotherapy or palliative radiotherapy
26
Q
Lung cancer surgery
A
- Segmentectomyorwedge resectioninvolves taking a segment or wedge of lung (a portion of one lobe)
- Lobectomyinvolves removing the entire lung lobe containing the tumour (the most common method)
- Pneumonectomyinvolves removing an entire lung
- A chest drain is left in after thoracic surgery: allows air and fluid to exit and the lungs to expand
27
Q
Palliative care for lung cancer
A
- Palliative radiotherapy for symptom control
- Endobronchial stenting or debulking for bronchial obstruction
- Pleural drainage or aspiration for pleural effusion
- Dexamethasone therapy for those with symptomatic brain metastasis
- Opioid therapy to relievecoughand breathlessness
28
Q
Risk factors for prostate cancer
A
- Increasing age
- Family history
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids
29
Q
Presentation for prostate cancer
A
- Asymptomatic- lower urinary tract symptoms
- Haematuria, haematospermia
- Erectile dysfunction
- Pain: back, perianal or testicular
- Bladder outlet obstruction: hesitancy, urinary retention
- Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)
30
Q
Consider a PSA and digital rectal exam
A
Any lower urinary tract symptoms, such asnocturia, urinary frequency, hesitancy, urgency or retention or
* erectile dysfunction or
* visiblehaematuria.
31
Q
Investigations for prostate cancer
A
- PSA
- Prostate exam: hard, firm, asymmetrical, craggy or irregular
- Prostate biopsy: do if Likert 3 or above. Can be false negative if miss the cancerous zone. Types of prostate biopsies: Transrectal ultrasound guided biopsy (TRUS), Transperineal biopsy
- Multiparametric MRI: reported on a Likert scale
- Isotope bone scan: to look for boney metastasis
- Transrectal ultrasound guided (TRUS) biopsy
32
Q
Management for prostate cancer
A
- Surveillanceorwatchful waitingin early prostate cancer
- External beam radiotherapydirected at the prostate: side effect is proctitis
- Brachytherapy: implanting radioactive seeds into the prostate
- Hormone therapy: Androgen receptor blockeer (bicalutamide), GnRH agonists such as goserelin (Zoladex) or leuprorlin (Prostap), Bilateral orchidectomy to remove testicles
- Surgery: radical prostatectomy removes the entire prostate
33
Q
PSA levels may be raised if
A
- benign prostatic hyperplasia(BPH)
- prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
- ejaculation (ideally not in the previous 48 hours)
- vigorous exercise (ideally not in the previous 48 hours)
- urinary retention
- instrumentation of the urinary tract
34
Q
Diagnose PAD
A
Colour duplex US
35
Q
Treatment for B12 deficiency
A
- Initially Hydroxocobalamin 1mg IM three times a week for two weeks
- If not diet related continue Hydroxycobalamin
- If diet related take cyanocobalamin tablets
36
Q
Bloods to order before starting statins
A
- U+Es
- LFTs
- HbA1c OR fasting glucose
- TFTs and “on T4” ticked
- Cholesterol
- Lipid profile
- Creatine kinase
37
Q
Differentiating SIADH and diabetes insipidus
A
- DI: thirst and dilute urine. Hypernatremia, low urine osmolality, maybe Hyperglycaemia
- SIADH: Hyponatraemia, high urine osmolality, low serum osmolality
38
Q
Acute tubular necrosis vs Acute interstitial nephritis
A
- Acute tubular necrosis: wont respond to fluid challenge, can be secondary to rhabdomyolysis. Muddy brown casts on urinalysis. Most common intrinsic cause of AKI
- Acute interstitial nephritis: mostly caused by drugs. Presents with fever, rash and arthralgia. Would see raised eosinophils
39
Q
B12 neurology
A
- Either presents with Subacute combined degeneration of the spinal cord (SACD) or peripheral neuropathy
- SACD: bilateral loss of proprioception and vibration. Classic triad: extensor plantars, brisk knee reflexes and absent ankle jerk
- Peripheral neuropathy: sensory loss predominant
