Cancer Flashcards
Referral recommendation for skin lesion suspected of a basal cell carcinoma?
- consider routine referral
- only 2ww (suspected ca referral) referral if concern that delay may have impact eg. due to factors such as site or size
When to refer pt using suspected ca pathway referral (appointment within 2w) for melanoma?
1) suspicious pigmented skin lesion with weighted 7 point checklist score of 3 or more
or
2) dermoscopy suggests melanoma
3) pigmented or non-pigmented lesion that suggests nodular melanoma
4) suspected SCC
5) BCC but concern that delay will have signif impact eg. due to size or site
Pigmented lesion on the skin?
?melanoma
Can get what type of melanomas rarely?
nodular and amelanotic
What checklist is used to assess pigmented skin lesions?
7-point checklist
Melanoma may present when?
after spread to regional lymph nodes or wider mets
Main method to diagnose melanoma?
excision biopsy in secondary care
Raised lesion on skin?
?SCC
Diagnose SCC?
possible to visually but confirm by excision biopsy
Ulcer with raised rolled edge; prominent fine blood vessels around a lesion or nodule on the skin (pearly or waxy)?
Basal cell carcinoma
Diagnosis of BCC?
possible visually but confirm by excision biopsy
7-point checklist for suspected melanoma?
Major (2 points each):
- change in size
- irregular shape
- irregular colour
Minor (1 each):
- largest diameter 7mm+
- inflam
- oozing
- change in sensation
Most common type of ca in Western world?
BCC
BCC characteristics?
- lesions also called Rodent ulcers
- slow growth
- local invasion
- mets v rare
Most common type of BCC?
nodular
Nodular BCC?
- sun exposed sites eg. head, neck
- initially= pearly, flesh coloured papule with telangiectasia
- later= ulcerate leaving central crater
Mx options for BCC?
- surgical removal
- curettage
- cryotherapy
- topical cream= imiquimod, fluorouracil
- radiotherapy
Bladder ca commonly affects who?
males 50-80yrs
RFs for bladder ca?
- male
- current or previous (within 20yrs) smokers
- exposure to hydrocarbons eg. 2-Napthylamine
- chronic bladder inflam from Schistosomiasis infection= SCC
-rubber manufacture - cyclophosphamide
Exposure to hydrocarbons eg. benzidine or 2-Naphthylamine from exposure to aniline dyes (eg. working in printing and textile industry) increases the risk of what?
bladder ca
examples of benign tumours of the bladder? (uncommon)
- inverted urothelial papilloma
- nephrogenic adenoma
Examples of bladder malignancies?
- Urothelial (transitional cell) carcinoma (>90%)
- SCC (1-7% expect is higher in regions affected by schistosomiasis- rare in UK)
- Adenocarcinoma
Most common bladder malignancy?
urothelial (transitional cell) carcinoma (>90%)
Urothelial carcinomas may arise as what?
solitary lesions or may be multifocal causing ‘field change’ within the urothelium
Growth pattern of urothelial carcinomas?
- 70% have papillary growth pattern= superficial and better prognosis
- mixed papillary and solid growth or pure solid growth= more prone to local invasion and may be higher grade, worse prognosis
Those with T3 disease or worse in urothelial carcinoma have a 30%+ risk of what?
regional or distant lymph node metastasis
TNM staging for bladder cancer= T?
T0= No evidence of tumour
Ta= Non invasive papillary carcinoma
T1= Tumour invades sub epithelial connective tissue
T2a= Tumor invades superficial muscularis propria (inner half)
T2b= Tumor invades deep muscularis propria (outer half)
T3= Tumour extends to perivesical fat
T4= Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a= Invasion of uterus, prostate or bowel
T4b= Invasion of pelvic sidewall or abdominal wall
TNM staging of bladder cancer: N?
N1= Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
N2= Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
N3= Lymph node metastasis to the common iliac lymph nodes
Painless macroscopic haematuria?
?bladder ca
CP of bladder ca?
- painless marcoscopic haematuria
- incidential microscopic haematuria= 10% females >50yrs found to have malignancy after infection excluded
Staging for bladder ca?
1) cystoscopy and biopsy or TURBT= histological diagnosis and depth of invasion
2) Pelvic MRI= locoregional spread
3) CT= distant disease
4) PET CT= nodes of uncertain significance
Tx for bladder ca?
superficial lesions= TURBT in isolation
recurrences or higher grade/risk on histology= intravesical chemo
T2 disease= surgery (radical cystectomy and ileal conduit) or radical radiotherapy
Prognosis of bladder ca?
T1 90%
T2 60%
T3 35%
T4a 10-25%
Any T, N1-N2 30%
How is cancer classified into types?
based on origin and characteristics of the abnormal cells
Carcinoma definition?
arises from epithelial cells that line internal organs and external surfaces
Types of carcinoma?
- adenocarcinoma
- SCC
- BCC
- transitional cel carcinoma
Most common types of cancer?
carcinoma
Types of carcinoma: adenocarcinoma definition?
develops in glandular tissues eg. breast, prostate, colon, pancreas
Types of carcinoma: SCC definition?
found in squamous cells eg. skin or lining of organs, for example lungs, oesophagus
Types of carcinoma: BCC definition?
form of skin cancer that starts in the basal cells
Types of carcinoma: transitional cell carcinoma definition?
arises in lining of the bladder, ureters and renal pelvis
Sarcoma definition?
develops in connective or supportive tissues such as bone, muscle, fat, cartilage and blood vessels
less common than carcinomas but more aggressive
Types of sarcoma?
- osteosarcoma
- chondrosarcoma
- liposarcoma
- leiomyosarcoma
Types of sarcoma: osteosarcoma definition?
originates in bone
Types of sarcoma: chondrosarcoma definition?
arises in cartilage
Types of sarcoma: liposarcoma definition?
develops from fat tissue
Types of sarcoma: leiomyocarcoma definition?
develops in smooth muscle tissue
Leukemia definition?
cancers of the blood-forming tissues, incl. bone marrow and lymphatic system
Types of leukemia?
- Acute Lymphoblastic Leukemia (ALL)
- Acute Myeloid Leukemia (AML)
- Chronic Lymphocytic Leukemia (CLL)
- Chronic Myeloid Leukemia (CML)
Types of leukemia: Acute Lymphoblastic Leukemia (ALL) definition?
affects lymphoid cells, common in children
Types of leukemia: Acute Acute Myeloid Leukemia (AML) definition?
affects myeloid cells, more common in adults
Types of leukemia: Chronic Lymphocytic Leukemia (CLL) definition?
slow-growing form affecting lymphoid cells
Types of leukemia: Chronic Myeloid Leukemia (CML) definition?
affects myeloid cells, progresses slowly
Lymphoma definition?
ca of the lymphatic system, which is part of the immune system
relatively common, esp non-Hodgkin
Types of lymphoma?
- Hodgkin Lymphoma (Hodgkin’s disease)
- Non-Hodgkin Lymphoma (NHL)
Types of lymphoma: Hodgkin Lymphoma definition?
characterised by presence of Reed-Sternberg cells
Types of lymphoma: Non-Hodgkin Lymphoma definition?
diverse group of lymphomas that don’t have Reed-Sternberg cells; including B-cell and T-cell lymphomas
Myeloma definition?
ca of plasma cells, type of WBC in bone marrow
rare form of ca, affects mainly older adults
Type of myeloma?
multiple myeloma
Type of myeloma: multiple myeloma definition?
most common form, affecting many areas of body incl. bones and kidneys (Old CRAB)
Melanoma definition?
ca than originates in melanocytes, the cells that produce the pigment melanin in the skin
less common than other skin ca (B/SCC) but more aggressive
Types of melanoma?
- cutaneous melanoma
- ocular melanoma
Types of melanoma: cutaneous melanoma definition?
starts in skin
Types of melanoma: ocular melanoma?
rare form that starts in the eye
Central Nervous System (CNS) cancers definition?
ca that begin in brain or spinal cord
can be mild or highly malignant, glioblastoma one of most severe
Common types of CNS cancers?
- glioblastoma
- astrocytoma
- meningioma
Types of CNS cancers: glioblastoma definition?
highly aggressive form of brain cancer
Types of CNS cancers: astrocytoma definition?
originates in star-shaped brain cells called astrocytes
Types of CNS cancers: meningioma definition?
affects meninges, the protective layers around brain and spinal cord
Germ Cell tumours definition?
arises from the cells that give rise to sperm or eggs (germ cells)
most common in adolescents and young adults
Common locations of germ cell tumours?
usually develop in testes (testicular ca) or ovaries (ovarian germ cell tumours) but can form in other parts of body eg. brain
Neuroendocrine tumours definition?
arise from cells that release hormones into the blood in response to signals from NS
rare and can be slow-growing, some can be aggressive
Types of neuroendocrine tumours?
- carcinoid tumours
- pheochromocytoma
Types of neuroendocrine tumours: carcinoid tumours?
type of neuroendocrine tumour commonly found in GI tract and lungs
Types of neuroendocrine tumours: pheochromocytoma?
typically arises in adrenal glands
Blastoma definition?
typically arises in embryonic tissue or immature cells, usually seen in children
Common types of blastoma?
- retinoblastoma
- neuroblastoma
- hepatoblastoma
Common types of blastoma: retinoblastoma definition?
ca of the retina, typically in young children
Common types of blastoma: hepatoblastoma definition?
rare liver ca in children
Common types of blastoma: neuroblastoma definition?
starts in immature nerve cells, often in adrenal glands
Mesothelioma definition?
rare ca that affects lining of lungs, abdo or heart; often linked to asbestos exposure
Thyroid ca definition?
ca that forms in thyroid gland, with types like papillary, follicular, medullary and anaplastic thyroid ca
Types of cancers?
- carcinoma
- sarcoma
- leukemia
- lymphoma
- myeloma
- melanoma
- CNS ca
- germ cell tumours
- neuroendocrine tumours
- blastoma
- mesothelioma
- thyroid cancer
What is the TNM staging used for?
to classify and describe details about the ca size, location and degree of spread, helps in planning treatment and estimating prognosis
primarily for solid tumours eg. breast, lung, colon
TNM staging: what is T?
Tumour
size and extent of the primary tumour
TNM staging: what is N?
Nodes
indicates whether the cancer has spread to nearby lymph nodes (local spread)
TNM staging: what is M?
Metastasis
refers to whether the ca has spread (metastasised) to distant organs or tissues (distant spread)
What would Tx, Nx or Mx mean in TNM staging?
can’t be assessed
Cancer stage grouping?
use TNM to combine into overall stage grouping: stage I, II, III or IV
some may have substage eg. IA or IIB depending on additional factors eg. tumour grade or specific molecular markers
Cancer stages?
0= cancer in situ (localised and not spread)
I= small tumour, localised, without spread to lymph nodes
II= large tumour or has spread to nearby lymph nodes, but no distant mets
III= more advanced local/regional spread to lymph nodes or nearby tissues, but no distant mets
IV= metastatic ca- has spread to distant parts of the body
TNM staging: what if the difference between N and M if in N the ca is still spreading?
N= local or regional involvement within the lymphatic system
M= ca has spread beyond original area and reached distant organs or tissues
so N is not considered metastasis
Brain and CNS cancers typically affect who?
children and young people
Symptoms of brain and CNS cancers?
new onset seizures, headaches, nausea, drowsiness, visual change, personality change
Ix/Mx for brain and CNS cancers in adults?
urgent direct access of MRI of brain or CT if MRI contraindicated, within 2w, in adults with progressive, sub-acute loss of central neurological function
Ix/Mx for brain and CNS cancers in children/young people?
very urgent referral (within 48hrs) in children with newly abnormal cerebellar or other central neurological function
Most common intracranial tumours in adults?
brain metastases
What do brain mets signify?
advanced disease state with significant impact on morbidity and mortality
What primary cancers are most likely to metastasise to the brain?
Lung (40-50%)
Breast (15-25%)
Melanoma (5-20%)
Renal (5-10%)
Colorectal
Pathways of spread for brain mets?
- hematogenous spread (most common)= via arterial circulation
- lymohatic (less common)= typically involves leptomeningeal carcinomatosis
- direct extension (rare)= from head and neck cancers
CP of brain mets?
- headache (worse in morning)
- neuro deficit (eg. hemiparesis, aphasia)
- seizures
- cognitive and behavioural changes
- symptoms of ICP= N&V, altered consciousness
Diagnosis of brain mets?
GOLD= MRI with contrast for number, size and location
- Biopsy confirms in primary ca site is unknown or imaging inconclusive
Aim of Mx of brain mets?
controlling symptoms, reducing tumour burden and improving QOL
Mx for brain mets?
- supportive care
- radiation therapy
- systemic therapy
- surgical resection
Mx for brain mets- supportive care?
- corticosteroids eg. dexamethasone= reduce peritumoral oedema and control symptoms eg. headache
- anticonvulsants= seizures
- palliative care for end-of-life
Mx for brain mets- radiation therapy, when is it used?
Whole Brain Radiotherapy (WBRT)= for multiple mets but associated with notable cognitive decline
Stereotactic Radiosurgery (SRS)= if 1-3 mets; offers high dose radiation with minimal damage to surrounding tissues
Mx for brain mets: systemic therapy?
chemotherapy, targeted therapy or immunotherapy depending on primary tumour type and molecular characteristics
used to better systemic control and penetration of blood brain barrier
Mx for brian mets: when is surgical resection indicated?
for accessible lesions causing signif mass effect or when histologic diagnosis required; improves neuro function and allows more effective adjuvant therapy
Prognosis of brain mets?
- generally poor but improving with targeted therapies and precision medicine
- median survival ranges= several months to over a yr
- depends on Tx and tumour biology
What drug class in tamoxifen?
selective oestrogen receptor modulator (SERM)= acts as an oestrogen receptor antagonist and partial agonist
Drug used in the Mx of oestrogen receptor positive breast ca?
tamoxifen
Adverse effects of tamoxifen (SERM)?
- vaginal bleeding, amenorrhoea
- hot flushes (3% stop taking due to this)
- VTE
- endometrial ca
What drug class are anastrozole and letrozole?
aromatase inhibitors= reduces peripheral oestrogen synthesis
Drug used in the Mx of ER +ve breast ca in postmenopausal women?
Anastrozole
Why is anastrozole used for ER +ve breast ca in postmenopausal women?
it is an aromatase inhibitor that reduces peripheral oestrogen synthesis; important as aromatisation accounts for majority of oestrogen production in postmenopausal women
Adverse effects of anastrozole (aromatase inhibitor)?
- osteoporosis (DEXA scan)
- hot flushes
- arthralgia, myalgia
- insomnia
What should be done when initiating pt on aromatase inhibitors for breast ca?
DEXA scan due to risk of osteoporosis
Malignant breast lump is usually what?
painless, but pain can occur
Nipple symptoms of breast ca?
shape in shape, bleeding, tethering, peau d’orange
Diagnosis of breast ca?
mammography and core biopsy
Who to refer for suspected ca referral (2ww) for breast ca?
- 30yrs+ with unexplained breast lump with or without pain
- 50yrs+ and any of: discharge, retraction, changes of concern; in one nipple
Consider a suspected ca referral (2ww) for breast ca in who?
- skin changes that suggest breast ca
- 30yrs+ with unexplained lump in axilla
Non-urgent referral for breast ca in who?
<30yrs with unexplained breast lump with or without pain
Symptoms suggestive of breast ca?
- axillary lump (unexplained)
- breast lump (unexplained)
- nipple changes
- skin changes
- DVT
Types of referrals for ca?
- immediate= acute admission or referral within few hrs
- urgent= within 2w
- very urgent= within 48hrs
- non-urgent= general referral
- suspected ca pathway= within national target for ca referral eg. 2ww
Most common type of breast ca?
invasive ductal carcinoma
Pathological assessment of breast ca involves what?
assessment of the tumour and lymph nodes- normally using sentinel lymph node biopsy (minimises morbidity of an axillary dissection)
Reconstruction for breast ca?
- option following any resectional procedure but type tailored to age and co-morbidities
- common: latissimus dorsi myocutaneous flap and sub pectoral implants
- want to avoid prosthesis= TRAM or DIEP flaps
Surgical options for breast ca: when is mastectomy indicated?
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS >4cm
- Pt choice
Surgical options for breast ca: when is wide local excision indicated?
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS <4cm
- pt choice
Large breast tumour that is unsutiable for breast conserving surgery?
mastectomy
How may central lesions in breast ca be managed?
breast conserving surgery where an acceptable cosmetic result may be obtained- rare in small breasts but more likely in large breast
Local recurrence rate of breast ca whatever surgery option was chosen?
5% or less at 5yrs
What index can be used to give indication of survival in breast ca?
Nottingham Prognostic Index
Calculation of Nottingham Prognostic Index?
Tumour Size x 0.2 + Lymph node score +Grade score
Nottingham Prognostic Index- lymph node and grade score score?
Score 1= 0 lymph nodes involved= Grade 1
Score 2= 1-3 lymph nodes= Grade 2
Score 3= >3= Grade 3
Prognosis from Nottingham Prognostic Index for breast ca?
score 2-2.4= 93% 5yr survival
score 2.5-3.4= 85%
3.5-5.4= 70%
> 5.4= 50%
What does Nottingham Prognostic Index for breast ca not include that can affect survival?
vascular invasion and receptor status
Prior to surgery for breast ca, what determines Mx?
presence or absence of lymphadenopathy
Mx of breast ca: women with no palpable axillary lymphadenopathy at presentation should have what?
pre-op axillary USS before primary surgery
if -ve then sentinel node biopsy to assess nodal burden
Mx of breast ca: women with palpable axillary lymphadenopathy at presentation should have what?
axillary node clearance at primary surgery
In the Mx of breast ca, what may happen if pt has axillary node clearance at primary surgery?
may lead to arm lymphedema and functional arm impairment
Mx of breast ca: when is whole breast radiotherapy recommended?
- all women after wide-local excision (can reduce recurrence by 2/3rds)
- if had mastectomy and have T3-T4 tumours
- if had mastectomy and have 4 or more +ve axillary nodes
When is adjuvant hormonal therapy offered for breast ca Mx?
if tumours are positive for hormone receptors
What receptors are tested for breast ca at time of initial histopathological diagnosis?
oestrogen receptor (ER), progesterone receptor (PR) or human epidermal growth factor receptor 2 (HER2)
Adjuvant hormonal therapy for breast ca after surgery if +ve for hormone receptors?
Tamoxifen= men and premenopausal women with ER +ve invasive breast ca
Aromatase inhibitor eg. anastrozole= postmenopausal women with ER +ve
Biological therapy for breast ca?
Trastuzumab (Herceptin) for HER2 positive breast ca
3 w intervals for 1yr in combination to surgery, chemo, endocrine therapy and radiotherapy as appropriate
Chemotherapy for breast ca?
Regimen with a taxane and an anthracycline
Side effects of chemo for breast ca (regimen that contains a taxane and an anthracycline)?
neuropathy, neutropenia and hypersensitivity
When to give bisphosphonate therapy in the Mx of breast ca?
zoledronic acid as adjuvant therapy to post-menopausal women with node +ve invasive breast ca or node -ve but high risk recurrence
What to offer pts who are not receiving bisphosphonates who are starting aromatase inhibitors, treatment induced menopause or starting ovarian ablation/suprression therapy in Mx of breast ca?
DEXA scan
What radiotherapy is offered for pts with invasive breast ca having partial breast, whole breast or chest-wall radiotherapy without regional lymph node irradiation after breast conserving surgery or mastectomy?
external beam radiotherapy: 26Hy in 5 fractions over 1w
Chemo Mx for people with ER/PR/HER2 negative (triple negative) invasive breast ca?
neoadjuvant chemo regimen contains a platium and an anthracycline
Genetic testing for breast ca?
BRCA1 and BRCA2 mutations
if under 50yrs with triple-negative breast ca and also those with no FHx of breast/ovarian ca
Mx for Paget’s disease?
Offer breast-conserving surgery with removal of the nipple–areolar complex as an alternative to mastectomy for people with Paget’s disease of the nipple that has been assessed as localised.
Breast reconstruction options for breast ca?
immediate reconstruction (during mastectomy surgery) or delayed in another operation
Cx of local treatment of breast ca?
- lymphoedema= arm, breast or chest wall
- arm and shoulder mobility= so carry out upper limb exercises
- menopausal symptoms
HRT and breast ca?
- stop HRT
- don’t offer HRT if Hx of breast ca
- consider SSRI to relieve symptoms if not on tamoxifen
What can you consider for premenopausal women with ER +ve invasive breast ca?
ovarian function suppression to reduce risk of recurrence
How long to take tamoxifen or aromatase inhibitor for breast ca?
5yrs
can continue taking to reduce recurrence
Can pt get pregnant on tamoxifen?
not while taking it or within 2m of stopping
Follow up imaging for pt who has been treated for breast ca?
annual mammography for 5yrs or longer until they enter screening programme
Summary of Mx of breast ca?
- Genetic testing= BRCA1 & BRCA2
- Hormone receptor testing= ER, PR, HER2
- Pre-op= USS axilla (if abnormal then USS guided needle sampling)
- Surgery= mastectomy or breast conserving surgery. Also axillary lymph node clearance or SLNB (if no evidence of LN invol on USS)
- Breast reconstruction= immediate or delayed
- Endocrine therapy= tamoxifen (ER) or anastrasole (PR) (and maybe extended endocrine therapy- >5yrs)
- Ovarian function supression
- Adjuvant chemo
- Radiotherapy= after breast conserving surgery or after mastectomy who are high risk of recurrence (eg. node +ve invasive breast ca)
- Biological theraoy= transtuzumab (HER2)
- Bisphosphonate?
Risk factors for breast ca?
- BRCA1, BRCA2 genes
- 1st degree relative premenopausal relative with breast cancer (e.g. mother)
- nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
- early menarche, late menopause
- combined hormone replacement therapy, combined oral contraceptive use
- past breast cancer
- not breastfeeding
- ionising radiation
- p53 gene mutations
- obesity
- previous surgery for benign disease (?more follow-up, scar hides lump)
BRCA1 and BRCA2 gene increase risk of what?
40% lifetime risk of breast/ovarian ca
What is used for breast screening?
mammography radiography- detects small changes in breast before other S&S of breast ca develop
How often is the breast screening programme?
every 3yrs
When are women offered breast screening?
aged 50-70
should receive 1st invitation within 3yrs of 50th bday
Can women >70yrs get breast screening?
excluded from programme but can get screening by self-referral to local breast screening service
Who may be eligible for breast screening <50yrs?
if have increased risk eg. strong FHx
What info should women be given before participating in breast screening programme
- benefits and harms
- organisation of screening
- where it is done
- preparing for mammogram
- what to expect during appointment
Benefits of breast screening?
- early detection of breast ca
- reduction in mortality
Harms of breast screening?
- over-diagnosis & unnecessary Tx
- false positive mammograms
- false reassurance so incorrect diagnosis
- pain and discomfort
- psychological distress, anxiety following a false positive
What people should be referred to breast clinic for screening from younger age?
- one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or
- one first-degree male relative diagnosed with breast cancer at any age, or
- one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or
- two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or
- one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or
- second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or
- three first-degree or second-degree relatives diagnosed with breast cancer at any age
What if mammogram comes back suspicious for breast ca?
1) mammogram
2) USS
3) if imaging concerning then biopsy: core needle biopsy
4) Pathology report= type of ca, hormone receptor status and grade
5) Staging= sentinel lymph node biopsy, CT
Types of breast cancer?
- invasive ductal carcinoma
- invasive lobular carcinoma
- ductal carcinoma-in situ (DCIS)
- lobular carcinoma-in-situ (LCIS)
Most breast cancers arise from what?
Duct tissue (most) or lobular tissue (so ductal or lobular carcinoma)
carcinoma-in-situ= local- hasn’t spread
invasive= spread
Invasive ductal carcinoma?
most common type breast ca
(recently been named as No Special Type (NST); lobular and other rarer types classed as Special Type)
Rarer types of breast cancer?
- Medullary breast cancer
- Mucinous (mucoid or colloid) breast cancer
- Tubular breast cancer
- Adenoid cystic carcinoma of the breast
- Metaplastic breast cancer
- Lymphoma of the breast
- Basal type breast cancer
- Phyllodes or cystosarcoma phyllodes
- Papillary breast cancer
Other types of breast cancer that may be associated with underlying lesions (eg. other types of breast ca)?
- Paget’s disease of the nipple
- Inflammatory breast ca
Paget’s disease of the nipple?
Eczematoid change of nipple associated with underlying breast ca
1-2% will have breast ca
1/2 have associated underlying mass lesion and 90% have invasive carcinoma
Some without mass lesion will have underlying carcinoma and some will have carcinoma in situ
Inflammatory breast ca?
cancerous cells block lymph drainage resulting in inflamed appearance of breast
rare
Most cases of cervical ca originate from where?
ecto- or endocervical mucosa in the cervical transformation zone
Cervical ca: what usually regressess?
low-grade dysplasia (cervical intraepithelial neoplasia 1- CIN1)
but can progress to high grade dysplasia
When does cervical ca occur?
when high grade dysplastic lesions extend beyond the basement membrane of the cervical epithelium
2 most common types of cervical ca?
squamous cell carcinoma and adenocarcinoma
Main cause of cervical ca?
persistent infection- HPV (human papillomavirus)
How is HPV trsansmitted?
sexual intercourse
What subtype of HPV account for 2/3rds of cervical ca?
16 and 18; 33
HPV detected in 99% cervical ca
Only about 10% of all HPV infections become persistent, which puts women at risk of developing what?
precancerous cervical lesions
Time interval between HPV infection and development of precancerous lesions?
1-10yrs
RFs for development of cervical ca?
- increased exposure to HPV (eg. early age 1st intercourse)
- impaired immune response to HPV infection eg. HIV or solid organ transplant
- smoking
- high parity
- lower socioeconomic status
- COCP
Peak incidence rate of cervical ca?
30-34yrs
Cx of cervical ca?
- psychosocial issues
- sexual dysfunction
- early menopause
- loss of fertility
- bladder & bowel dysfunction
- pelvic or other pain
- renal failure
- haemeorrhage
- fistuale
- lymphoedema
CP of cervical ca?
- abnorm vaginal bleeding or discharge (not 2 to infection or other causes)
- pelvic pain +/- dyspareunia
- postmenopausal bleeding not due to HRT
- abnorm cervix on exam= inflamed or friable, contact bleeding, visible ulcerating or necrotic lesion
- symptoms of advanced disease (rare)
What to do if suspect cervical ca?
- urgent suspected ca referral (2ww) to colposcopy/gynaecology oncology
- abdo, speculum and bimanual pelvic exam (may look normal)
- assess for lymphadenopathy= inguinal and supraclavicular
Prevention of cervical ca?
- national cervical screening programme
- national HPV vaccination programme
- consistent use of condoms and practicing safe sex
Differential diagnosis for cervical ca?
- STI
- Endometrial ca
- endometriosis
- ectropion or cervical polyp
- hormonal contraception (in 1st 3m or 3-6m with coil or implant)
2 ww referral for cervical ca?
All women with unexplained postmenopausal bleeding should be referred to gynaecology for specialist assessment.
Don’t delay referral because a woman has had a previously normal cervical screening result
Don’t delay referral until after pregnancy if a woman is pregnant.
Cervical ca initial assessment after referral?
punch or excisional biopsy eg. electrosurgical excision and conization of suspicious lesions
What when cervical ca is confirmed after biopsy?
staging using FIGO system
- MRI: tumour size and extent
- CXR and assessment for hydronephrosis (renal USS, CT or MRI) for pre-Tx
- sentinel node biopsy + PET/CT for lymph node invol. and mets
Common sites of mets from cervical ca?
lungs, liver, bone
Mx for cervical ca= Stage IA1 (microinvasive)
- loop electrosurgical excision and conisation: aim to acheive -ve margins to both ca and dysplasia
- simple hysterectomy if don’t want to preseve fertility
Mx for cervical ca: Stages IA2-IB2 (early stage disease)?
- radical hysterectomy and bilateral salpingectomy ( if fertility sparing appropriate in low risk) and/or bilateral oophorectomy with bilateral pelvic lymphadenectomy
- radical trachelectomy (removal of cervix) and lymphadenoectomy can be considered instead for small tumours
- may have adjuvant chemo or radio if intermediate/high risk recurrence
What factors may determine risk of recurrence in cervical ca?
tumour size, margin invl, lymph node invl
Mx for cervical ca: Stage IB3-IVA (locally advanced)?
- external beam radio, intracavity brachytherapy (radiation source placed in uterus & vagina) and chemo 1st line
- surgery not recommended as unlikely to be curative
Mx of cervical ca: Stage IVB (spread to distant organs)?
systemic chemo 1st line
Mx options for recurrent or metastatic cervical ca?
- salvage surgery= pelvic exenteration (removal of female reproductive organs, lower urinary tract, portion of rectosigmoid bowel) if chemo failed and confined to central pelvis
- chemo and/or radiotherapy if surgery not controlled disease
What is a radical hysterectomy?
resection of cervix, uterus, parametria and cuff of upper vagina
Most common type of cervical ca?
squamous cell cancer
Mechanism of HPV causing cervical ca?
HPV 16 & 18 produce the oncogenes E6 and E7 retrospectively
E6 inhibits p53 tumour supressor gene
E7 inhibits RB supressor gene
What is an oncogene?
mutated gene that has potential to cause cancer
What. HPV subtypes are non-carcinogenic and associated with genital warts?
6 & 11
Infected endocervical cells (infected with HPV) may undergo changes resulting in the development of what?
Koilocytes
Characteristics of koilocytes?
- enlarged nucleous
- irregular nuclear membrane contour
- nucleus stains darker than normal (hyperchromasia)
- perinuclear halo
What is the Mx of cervical ca determined by?
FIGO staging and wishes of pt to maintain fertility
Stages of the FIGO staging for cervical ca?
IA
IB
II
III
IV
FIGO staging for cervical ca: stage IA?
Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep
FIGI staging for cervical ca: stage IB?
Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter
FIGO staging for cervical ca: stage II?
Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
FIGO staging for cervical ca: stage III?
Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall
NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III
FIGO staging for cervical ca: stage IV?
Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
What is hydronephrosis?
urine builds up in kidneys due to blockage in ureters so they swell eg. can be a Cx of advanced cervical ca
Prognosis of cervical ca?
FIGO stage I= 99% 1yr survival; 96% 5yr
II= 85%; 54%
III= 74%; 38%
IV= 35%; 5%
Cx of cone biopsy or radical trachelectomy eg. in cervical ca?
preterm birth in future pregnancies
Cx of radical hysterectomy?
ureteral fistula
Short term Cx of radiotherapy for cervical ca?
diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
Long term Cx of radiotherapy for cervical ca?
ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
Cervical ca screening for women aged?
25-64yrs (first invitation issued at 24.5yrs so ensure screening can be done by 25th bday)
Recall intervals for cervical ca screening?
25-49yrs= recall every 3yrs
(invitations issued 34.5m after previous test)
50-64yrs= every 5yrs (58.5m after previous)
Can people 65yrs and older get cervical screening?
invited if recent cervical cytology abnormal
or
if not had screening since 50yrs and request one
What does NHSCSP (cervical screening) involve?
- HPV screening= identify people with high-risk HPV (hrHPV)
- Liquid based cytology (if hrHPV found)= detect early abnormalities of cervix, if untreated can lead to ca
- Colposcopy= diagnose cervical intraepithelial neoplasia (CIN) and to differentiate high-grade lesions from low-grade abnormalities in people with abnormal cytology
Cervical ca screening, what if hrHPV detected?
cytology
if this is abnormal then colposcopy
Cervical ca screening= hrHPV +ve and negative cytology?
repeat HPV test at 12m
- if -ve then return to normal recall
- if +ve then repeat HPV in 12m again
- if -ve at 24m then return normal recall
- if +ve at 24m then refer to colposcopy
Cervical ca screening= hrHPV +ve with cytology abnormal at 12 or 24m?
refer to colposcopy
Cervical ca screening= hrHPV test unavailable or cytology inadequate?
repeat sample in <3m
- if inadequate at 24m repeat text, these are exception and refer to colposcopy
- 2 consecutive inadequate or unavailable tests then refer to colposcopy
Cervical ca screening= colposcopy normal and adequate?
follow up at 12m screening, if then HPV -ve then return to normal recall
Cervical ca screening= colposcopy inadequate?
repeat screening and colposcopy in 12m; if normal and HPV -ve then return to routine recall
Cervical ca screening: cytology negative means what?
no abnormality detected
Cervical ca screening: if cytology is abnormal, the cervical samples may show what? (6)
- borderline changes in squamous or endocervical cells
- low grade dyskaryosis
- high-grade dyskaryosis (moderate)
- high-grade dyskaryosis (severe)
- invasive squamous cell carcinoma
- glandular neoplasia
Cervical ca screening: if cytology is inadequate, this may be because the cervical sample was…? (5)
- taken but the cervix was not fully visualised
- taken in inappropriate manner eg. using not approved sampling device
- contains insufficient cells
- contains obscuring element eg. lubricant, blood, inflamm
- incorrectly labelled
What does colposcopy look at in cervical ca screening?
any abnormal changes in cervix which may indicate pre-cancerous changes (cervical intraepithelial neoplasia [CIN]) or the presence of cancer
What chemicals are usually applied to cervix during colposcopy in cervical ca screening?
acetic acid = abnormal areas (such as CIN) tend to turn white (sometimes referred to as acetowhite).
If iodine solution= normal tissue (on the outside of the cervix) stains dark brown. Pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix do not stain brown.
What may be done on colposcopy to confirm diagnosis of cervical ca?
biopsy
Can pregnant women be offered cervical screening?
- if called while pregnant, defer until 3m post-partum +
- if previous test was abnormal, do not delay colposcopy (can do in late 1st or early 2nd tri; if low grade changes can delay until after delivery; if seen in early preg may need another assessment in late 2nd tri)
If pt has been treated for CIN, when should they be followed up for repeat cervical sample?
6m after Tx to test for cure
What is cervical intraepithelial neoplasia (CIN)?
abnormal changes in the transformation zone of cervix
Cervical dysplasia may indicate what?
HIV
Cervical intraepithelial neoplasia (CIN) grade 1 (CIN1)?
sometimes referred to as low-grade squamous intraepithelial lesions) — one-third of the thickness of the surface layer of the cervix is affected.
Cervical intraepithelial neoplasia (CIN) grade 2 (CIN2)?
two-thirds of the thickness of the surface layer of the cervix is affected.
Cervical intraepithelial neoplasia (CIN) grade 3 (CIN3)?
(sometimes called high-grade or severe dysplasia or stage 0 cervical carcinoma in situ) — the full thickness of the surface layer is affected.
CIN may exist at any one of the three stages, eg?
CIN1 lesions are morphological correlates of HPV infections.
CIN2/3 lesions (collectively referred to as CIN2+) are correlates of cervical pre-cancers that, if left untreated, may progress to cervical cancer.
How often should pt have cervical ca screening if have HIV?
annually and colposcopy at diagnosis
What does dyskaryosis in cervical ca mean?
percancerous changes in cervical cells: can be early indication of cervical ca or HPV infection
Cervical ca: mild dyskaryosis?
Indicates low-grade abnormalities in the cervical cells.
Often corresponds to CIN1, which is a mild change in the cells and typically linked to an HPV infection.
In many cases, mild dyskaryosis can resolve on its own without treatment, especially if caused by transient HPV infections.
Cervical ca: moderate dyskaryosis?
Indicates more significant abnormality.
Typically corresponds to CIN2 , which is a higher risk of progression to cervical cancer than CIN1.
Treatment may be needed to prevent further progression.
Cervical ca: severe dyskaryosis?
Indicates severely abnormal cells.
Usually corresponds to CIN3, a precancerous stage with a significant risk of progression to cervical cancer if untreated.
Requires further diagnostic testing and often surgical treatment to remove the abnormal tissue.
What if dyskaryosis is detected on cervical smear?
colposcopy +/- biopsy
Presenting features of colorectal ca may include what?
- change in bowel habits: C, D or alternating; increase frequency
- rectal bleeding: bright red or melena
- abdo pain/discomfort
- unexplained weight loss: advanced
-anaemia: fatigue, weakness, SOB - bowel obstruction: advanced- severe abdo pain, N&V
Why may pt get abdo pain/discomfort/cramping with colorectal ca?
may be due to tumour obstructing bowel or causing inflam
Why may pt with colorectal ca have anaemia?
chronic bleeding from the tumour
Locations of ca in colorectal cancer?
rectal (40%)
sigmoid (30%)
descending colon (5%)
transverse colon (10%)
ascending colon and caecum (15%)
Types of colorectal (colon) ca?
1) sporadic (95%)
2) hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
3) familial adenomatous polyposis (FAP, <1%)
What may sporadic colon ca be due to?
genetic mutations
Examples of genetic mutations that may cause colon (colorectal ca)?
- allelic loss of APC gene
- activation of K-ras oncogene
- deletion of p53 and DCC tumour suppressor genes
What is HNPCC (Lynch syndrome)?
autosomal dominant condition, most common form of inherited colon ca
90% pts develop ca, often proximal colon, poorly differentiated and highly aggressive
What mutation and genes are involved in HNPCC (Lynch syndrome)?
7 mutations, which affect genes invl in DNA mismatch repair leading to microsatelilite instability.
Genes:
- MSH2 (60%)
- MLH1
Pts with HNPCC are also at higher risk of what?
other ca eg. endometrial ca
What is sometimes used to aid diagnosis of HNPCC?
Amsterdam criteria:
- at least 3 family members with colon ca
- the cases span at least 2 generations
- at least one case diagnosed before age of 50yrs
What is FAP?
rare autosomal dominant condition which leads to formation of hundreds of polyps by age 30-40yrs
pts inevitably develop carcinoma (lifetime risk near 100%)
What is FAP due to?
mutation in tumour supressor gene called adenomatous polyposis coli gene (APC) located on chromosome 5
Ix and Mx for FAP?
Ix= genetic testing- analyse DNA from pts WBC
Mx= total proctocolectomy with ileal pouch anal anastomosis (IPAA) formation in their 20s
Pts with FAP are also at risk from what?
duodenal tumours
Variant of FAP?
Gardner’s syndrome- also feature osteomas of skull & mandible, retinal pigmentation, thyroid carcinoma and opidermoid cysts on the skin
What does FAP stand for?
Familial Adenomatous Polyposis
How to stage colorectal ca?
- carcinoembryonic antigen (CEA)
- CT chest, abdo, pelvis
- entire colon evaluated with colonoscopy or CT colonography
- if tumour lies below peritoneal reflection then also need mesorectum evaulated with MRI
Staging system for colorectal ca?
TNM
once staging complete then MDT meeting to formulate Mx plan
Treatment options for colorectal ca?
- surgery
- chemo
- radio
- targeted therapies
Ca of colon is nearly always treated with what?
surgery
Only option for cure in pts with colon ca?
resectional surgery
Confounding factors that will goven choice of procedure for surgery for colon ca?
eg. tumour pt from HNPCC family may be better served with panproctocolectomy rather than segmental resection
Treatment for colon ca: surgery- what is needed for anastomosis to heal?
following resection, need decision regarding restoration of continuity
for anastomosis to heal= adequate blood supply, mucosal apposition and no tissue tension
What is an anastomosis?
surgical or natural connection between 2 structures eg. blood vessels, intestine, tubes
critical in many surgeries to ensure that normal flow and function are maintained after structural changes
Surgical options when colon ca presents with an obstructing lesion?
stent it or resect
unusual now to defunction a colonic tumour with proximal loop stoma (this differs from situation in rectum)
The operations for colon ca are segmental resections based on what?
blood supply and lymphatic drainage
Type of resection and anastomosis for cancer of the caecal, ascending or proximal transverse colon?
Type of resection= right hemicolectomy
Anastomosis= ileo-colic
Type of resection and anastomosis for cancer of the distal transverse, descending colon?
Type of resection= left hemicolectomy
Anastomosis= colo-colon
Type of resection and anastomosis for cancer of the sigmoid colon?
Type of resection= high anterior resection
Anastomosis= colo-rectal
Type of resection and anastomosis for cancer of the upper rectum?
Type of resection= anterior resection (TME)
Anastomosis= colo-rectal
Type of resection and anastomosis for cancer of the low rectum?
Type of resection= anterior resection (low TME)
Anastomosis= colo-rectal (+/- defunctioning stoma)
Type of resection and anastomosis for cancer of the anal verge?
Type of resection= abdomino-perineal excision of rectum
Anastomosis= none
Types of stoma?
Colostomy: Bypass the colon, output is usually solid.
Ileostomy: Bypass the small intestine, output is usually liquid.
Urostomy: Bypass the bladder, output is urine.
Jejunostomy and Gastrostomy: Used for feeding rather than waste diversion. (opening in jejunum or in stomach respectively)
Temporary vs permanent stomas?
Temporary Stomas: Created when the bowel or bladder needs time to heal (e.g., after an injury or surgery). They are later reversed when healing is complete.
Permanent Stomas: Created when the underlying condition (e.g., cancer, severe Crohn’s disease) requires permanent removal or bypass of part of the digestive or urinary tract.
When is chemotherapy used in colorectal ca?
in neoadjuvant setting (particularly for rectal ca), adjuvant setting and for metastatic disease
Common chemo regimens for colorectal ca?
FOLFOX and FOLFIRI
When is radiation therapy used for colorectal ca?
predominantly for rectal ca in the neoadjuvant or adjuvant setting
Targeted therapies for colorectal ca?
Bevacizumab (anti-VEGF) and Cetuximab (anti-EGFR), particularly for metastatic disease
Emergency surgery in colorectal ca in a setting where the bowel has perforated so the risk of an anastomosis is much greater? (particulary when the anastomosis needed is colon-colon)
end colostomy is safer and can be reversed
- resection of sigmoid colon and end colostomy is fashioned in operation= Hartmann’s procedure
- left sided resections more risky, ileo-colic anastomoses are relatively safe even in emergencies and don’t need to be defunctioned
What is used to guide referral in suspected colorectal ca?
Faecal Immunochemical Test (FIT) instead of doing colonoscopy 1st line
What scenarios should pt get FIT test before colorectal ca referral?
- abdo mass
- change in bowel habit
- iron def anaemia
- 40yrs+ with unexplained weight loss & abdo pain
- <50yrs with rectal bleeding + abdo pain or weight loss
- 50yrs+ with rectal bleeding, weight loss or abdo pain
- 60yrs+ with anaemia even in absence of iron def
What if pt needs FIT test but already had a negative result through the NHS screening programme?
still need another one
What if pt with rectal mass, unexplained anal mass or unexplained anal ulceration?
do not need FIT test, just consider referral for ?colorectal ca
What if FIT test comes back +ve?
refer on suspected ca pathway
What if FIT test negative?
- safety net
- refer on suspected ca pathway if ongoing signif concern (abdo mass)
- still Ix for underlying diagnosis
NHS screening programme for bowel ca offered to who?
every 2yrs to people 50-74yrs (England & Scotland)
Wales: 51-74
NIreland: 60-74hrs
How is FIT testing done in NHS screening programme for bowel ca?
Invitation letter followed by test kit: end of test tick dipped into single bowel motion, placed back in tube and returned in envelope
How do pt get results from FIT test from the screening programme?
letter sent to pts home within 2 weeks of receiving the kit and GP informed electronically
Abnormal FIT test on NHS screening programme?
offered colonoscopy
Colonoscopy results if indicated after FIT test (following screening programme)?
No abnormal or low-risk adenoma= return to routine recall
Intermediate or high risk adenoma= invited for colonoscopic surveillance/review
Cancer= refer for Tx
Other pathology eg. IBD or diverticulosis= referred for Tx
Possible harms of bowel screening?
anxiety; Cx of colonoscopy (bleeding, bowel perforation); inappropriate reassurance from -ve screening result
How can primary care support the bowel ca screening programme?
- promoting uptake
- ensure that pts are aware that not all ca will be detected by screening
- -ve results should not be used to guide Ix of pt presenting with symptoms of bowel ca
What is a FIT test?
type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human Hb
used to detect and quantify amount of human blood in single stool sample
abnormal result offered colonoscopy
Most colorectal ca develop from what?
adenomatous polyps
If pt gets colonoscopy following FIT test, how many will be found to have ca?
1/10
5/10 normal
4/10 polpys which may be removed (premalignant potential)
Where is endometrial ca classically seen?
post-menopausal women
25% do occur before menopause
Prognosis of endometrial ca?
good due to early detection
RFs for endometrial ca?
XS oestrogen:
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen
metabolic syndrome:
- obesity
- DM
- PCOS
tamoxifen
hereditary non-polyposis colorectal carinoma (HNPCC)
Protective factors for endometrial ca?
- multiparity
- COCP
- smoking
Does HRT and the COCP increase or decrease the risk of endometrial ca?
Reduces the risk
addition of progestogen to oestrogen reduces the risk as oestrogen is no longer unopposed
Postmenopausal bleeding classic symptom of what?
endometrial ca
Features of endometrial ca?
- postmenopausal bleeding, usually slight and intermittent initially before becoming heavier
- premenopausal= menorrhagia or intermenstrual bleeding
- pain not common, signifies extensive disease
- vaginal discharge unusual
Who should be referred using suspected ca pathway for endometrial ca?
all women >=55yrs who present with postmenopausal bleeding
consider if <55
1st line Ix for endometrial ca once referred?
trans-vaginal USS: normal endometrial thickness (<4mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
Mx for endometrial ca?
surgery
- localised disease= total abdo hysterectomy with bilateral salpingo-oophorectomy
high-risk disease= postop radiotherapy
Frail elderly women with endometrial ca not suitable for surgery?
progestogen therapy
How is post-menopausal bleeding defined?
unexplained vaginal bleeding more than 12m after menstruation has stopped because of the menopause
Consider a direct access USS to assess for endometrial ca in women aged 55yrs and over with what?
Unexplained symptoms of vaginal discharge who:
- Are presenting with these symptoms for the first time, or
- Have thrombocytosis, or
- Report haematuria, or
Visible haematuria, and:
- Low haemoglobin levels, or
- Thrombocytosis, or
- High blood glucose levels.
Who is typically affected by gastric ca?
older people (1/2 are >75yrs) and male
Most common type of gastric ca?
gastric adenocarcinoma
Where does gastric adenocarcinoma arise from?
glandular epithelium of the stomach lining
RFs for gastric ca?
- Helicobacer pylori
- pernicious anaemic, atrophic gastritis
- diet
- ethnicity: Japan, China
- smoking
- blood group A
Why is H.pylori a RF for gastric ca?
triggers inflam of the mucosa -> atrophy and intestinal metaplasia -> dysplasia
What type of diet increases risk of gastric ca?
salt and salt-preserved foods
nitrates
Features of gastric ca?
abdo pain= vague, epigastric, dyspepsia
weight loss & anorexia
N&V
dysphagia: esp if ca arises in proximal stomach
overt upper GI bleeding in minority
Virchow’s node & Sister Mary Joseph’s node
What lymph nodes may be palpated if there is lymphatic spread in gastric ca?
left supraclavicular lymph node (Virchow’s node)
periumbilical nodule (Sister Mary Joseph’s node)
Ix and diagnosis for oesophago-gastric ca?
oesophago-gastro-duodenoscopy with biopsy
Signet ring cells?
may be seen in gastric ca on biopsy
contain large vacuole of mucin which displaces the nucleus to one side
high no. of signet ring cells= worse prognosis
How to stage gastric ca?
- CT chest, abdo and pelvis= ?mets
- endoscopic USS: if will guide Mx
- F18 FDG-PET scan: if ? metastatic disease
-pre-op staging laparoscopy: if potentially curable gastric
Mx of gastric ca?
surgical options depend on extent and site, include:
- endoscopic mucosal resection
- partial gastrectomy
- total gastrectomy
- chemotherapy
Mx of T1N0 oesophageal ca?
endoscopic mucosal resection for staging
Mx for T1bN0 SCC of the oeophagus?
- definitive chemo or
- surgical resection
pt choice
Surgical Tx of oesophageal ca?
open or minimally invasive oesophagectomy
Lymph node dissection in oesophageal and gastric ca?
When performing curative gastrectomy for gastric ca= consider D2 lymph node dissection
Curative oesophectomy= consider two-field lymph node dissection
Mx for localised oesophageal and oesophago-gastric junctional adenocarcinoma (excluding T1N0) who will have surgical rection, offer choice of what?
- chemo before or before & after surgery
- chemoradiotherapy before surgery
What to offer pt who is having radical surgical resection for gastric ca?
chemo before and after surgery
or chemo/chemoradiotherapy after surgery for those with curative intent and didn’t have chemo before
Mx for SCC of oesophagus (resectable and non-metastatic)?
- radical chemoradio or
- chemoradio before surgical resection
Mx for non-metastaic oesophageal ca that is not suitable for surgery?
palliative Mx:
- chemoradio for non-metastatic that can be encompassed within a radiotherapy field
if can’t be encompassed, consider 1 or more:
- chemo
- local tumour Tx (stenting or palliative radio)
- best supportive care
after Tx reassess response and reconsider if surgery is an option
1st line palliative chemo for people with HER2-positive metastatic adenocarcinoma of stomach or oesophago-gastric junction?
trastubzumab (in combination with cisplatin and capecitabine)
1st line palliative combination chemo to pt with advanced oesophago-gastric ca who have performance status 0 to 2 and no signif comorbidities?
double Tx= 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin
triple Tx= 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin.
What can you offer pts with luminal obstruction in oesophageal and oesophageal-gastric junctional ca?
self-expanding stents or radiotherapy
What can you offer pt with outflow obstruction in gastric ca?
uncovered self-expanding metal stents or palliative surgery
What to offer pt immediately after having radical surgery for oesophageal and oesophago-gastric junctional ca?
enteral or parenteral nutrition
Most common malignancy affecting children?
ALL
What does ALL stand for?
Acute lymphoblastic leukaemia
Peak incidence of ALL?
2-5yrs
boys slightly more common
Features of ALL may be divided into what?
those predictable by bone marrow failure eg. anaemia, neutropaenia, thrombocytopenia
Features of ALL?
- anaemia= lethargy and pallor
- neutropenia= frequent or severe infection
- thrombocytopenia= easily bruising, petechiae
- bone pain
- splenomegaly
- hepatomegaly
- fever in up to 50%
- testicular swelling
Why may child get bone pain with ALL?
secondary to bone marrow infiltration
Types of ALL?
- common ALL (75%), CD10 present, pre-B phenotype
- T-cell ALL (20%)
- B-cell ALL (5%)
ALL poor prognostic factors?
- age <2yrs or >10yrs
- WBC >20*10^9/l at diagnosis
- T or B cell surface markers
- non-Caucasian
- male
More common form of acute leukaemia in adults?
acute myeloid leukaemia
AML may occur as what?
primary disease or following a secondary transformation of a myeloproliferative disorder
What does AML stand for?
acute myeloid leukaemia
Features of AML?
related to bone marrow failure
- anaemia= pallor, lethargy, weakness
- neurtopenia= WBC count may be v high, functioning neutrophil levels may be low leading to frequent infections
- thrombocytopenia= bleeding
- splenomegaly
- bone pain
Poor prognostic factors of AML?
> 60yrs
20% blasts after first course of chemo
cytogenetics= deletions of chromosome 5 or 7
Classification of AML?
French-American-British (FAB)
MO - undifferentiated
M1 - without maturation
M2 - with granulocytic maturation
M3 - acute promyelocytic
M4 - granulocytic and monocytic maturation
M5 - monocytic
M6 - erythroleukaemia
M7 - megakaryoblastic
Acute promyelocytic leukaemia M3 (APML, the M3 subtype of AML)?
associated with t(15;17)
fusion of PML and RAR-alpha genes
presents younger than other types of AML (average = 25 years old)
Auer rods (seen with myeloperoxidase stain)
DIC or thrombocytopenia often at presentation
good prognosis
Don’t need to know substypes of AML except what?
Acute promyelocytic leukaemia (APML, the M3 subtype of AML)
What is APML associated with?
the t(15;17) translocation which causes fusion of the PML and RAR-alpha genes
Features of APML?
- presents younger than other types of AML (average=25yrs)
- DIC or thrombocytopenia often
- good prognosis
Mx of APML?
all-trans retinoic acid (ATRA) to force immature granulocytes into maturation to resolve a blast crisis prior to more definitive chemo
What type of leukaemia is treated with all-trans retinoic acid (ATRA) to force immature granulocytes into maturation to resolve a blast crisis prior to more definitive chemo?
APML (subtype of AML)
Cx of CLL?
- anaemia
- hypogammaglobulinaemia= recurrent infections
- warm autoimmune haemolytic anaemia (in 10-15%)
- transformation to high-grade lymphoma (Richter’s transformation)
What is Ritchter’s transformation?
occurs when leukaemia cells enter lymph node and change into high-grade, fast-growing non-Hodgkin’s lymphoma
pts become unwell very suddenly
Ritcher’s transformation is indicated by one the following symptoms….
lymph node swelling
fever without infection
weight loss
night sweats
nausea
abdominal pain
