cancer 2 Flashcards
What is melanoma ?
Dermatological cancer - cancer of the skin
0 usually presents as new or changing deeply pigmented lesion
0 3rd most common skin cancer - but most deadly skin cancer.
0 one of the most common forms of cancer in young adults.
0 arises from melanocytes in epidermis
(melanocytes mutate and proliferate. )
RISK FACTOR
0 family / personal history
0 Light eye, hair
0 high freckle density
0 immunosupression
0 multiple moles / melanocyctic naevi ( pigmented moles )
0 if there is a melanocytic navei that does not resemble surrounding ones. (iugly duckling )
MMRISK M - moles- atypical M - moles - common R - red hair / light hair I - Inability to tan / immunosupression S - Sunburn K - KINDRED ( FAMILY history)
SYMPTOMS
0 pigmented lesion
- deep
- ill defined
- asymmetric
- can bleed or ulcerate.
Management of suspected Melanoma ?
Examination of lesion - dermatoscopy (magnifying glass type structure then evaluate lesion)
A - asymmetry (one half not the same as the other )
B - borders (ill- defined, ragged )
C - colour changes
(inconsistent colour- varies)
D - diameter (larger than a pencil eraser)/ depth
E - elevation / evolution ( changes quickly)
- these is done to determine if a skin biopsy is needed.
Skin biopsy - essential fro diagnosis
What models are used to assess the depth of pigmented lesion ?
Clark level
0 Level 1 - contained within the epidermis
(melanoma in situ )
0 Level 2 - invaded into dermis (papillary dermis )- has access to BV
0 Level 3 - Traveled further into dermis
(reticular/ deep dermis )
0 Level 4 - traveled further into reticular dermis
0 Level 5 - reached hypodermis (subcutaneous tissue )
Breslow depth
Less than or equal (LTOE) 0.75mm = Clark level 2 (CL2)
- 76mm - 1.5mm = CL3
- 51mm -4mm = CL4
greater than 4mm = CL5
Types of breast cancer ?
0 breast cancer in situ
-DCIS - ductal carcinoma in situ - in the milk duct
- LCIS - Lobular carcinoma in situ - abnormal cells found in the milk glands / lobules or terminal ducts
(not cancer but at increase risk of developing breast cancer)
0 Primary invasive breast cancer
0 Metastatic breast cancer
Breast carcinoma in situ ?
Risk factors
Fx of breast cancer / personal history
breast lump nipple discharge (can be bloody or not )
breast cancer that is ignored can present as an ulcerating skin lesion.
Investigation of breast cancer in situ / breast lump?
Breast examination
Mammogram
(see calcifications )
Biopsy - fine needle or core
once confirmed
can do :
Sentinel lymph node biopsy (SNLB) - check spread.
IF MAMMOGRAM INCONCLUSIVE :
- ultrasound or r MRI can be done.
(MRI can be used in young people - as they have denser breast tissue which makes mammograms harder )
0 Hormone receptor testing done e.g ER or PR positive or negative.
Treatment of breast cancer in situ ?
low risk with DCIS
1st line
- surgical excision or mastectomy +/ - breast reconstruction (BR)
ADJUNCT - Axillary lymph node surgical staging (ALNSS)
* ( patients undergoing a lumpectomy - sentinal node biopsy is not recommended ) - but is for people who are having a mastectomy before the surgery.
ADJUNCT - radiotherapy
ADJUNCT - endocrine therapy e.g tamoxifen etc
( treat ER+ , PR + cancers )
WOMEN WITH HIGH RISK DCIS + ALL MEN
same as low risk only difference
1st line
Mastectomy +/- (BR)
LCIS
1st line
Observation & counselling
ADJUNCT - endocrine therapy
0 Tamoxifen - anti -oestrogen therapy (AE)
(in pre-menopausal and postmenopausal women),
0 Raloxifene, - blocks oestrogen binding and helps reduce osteoporosis (increases bone density )
0 Anastrozole -(Aromatase inhibitor )
0 Exemestane - aromatase inhibitor hormone antagonistblocks aromotase - converts androgens to estrogen (in postmenopausal women).
0 letrozole - aromatase inhibi
LCIS - high risk or high anxiety , strong Fx
1st line
Bilateral (Prophylatic mastectomy )
- Recurrance after breast conserving surgery (surgical excision with radiotherapy )
1st line
Mastectomy + BR
ADJUNCT -(ALNSS)
Recurrance after surgical excision without radiotherapy
1st line
- re- excision + radiotherapy
FOLLOWING MASTECTOMY
– re- excision + ADJUNCT radiotherapy
What does ER + , PR + , HER + breast cancers mean ?
ER + - breast cancers cells have estrogen receptors on their surface - estrogen binds causing them to grow.
(similar for PR + - progesterone )
RESPOND WELL TO HORMONE THERAPIES.
if receptors not present (ER- , PR - )
HER +
Some breast cancers have too much of a HER2 protein (human epidermal growth factor receptor 2) on the surface of their cells. extra HER2 encourages the cancer cells to divide and grow.
*Triple negative breast cancer - negative for all three.
What is primary invasive breast cancer ?
Cancer has penetrated past the basement membrane and spread to surrounding tissue but has not spread to other organs.
Treatment of primary invasive breast cancer ?
early stage breast cancer - (stage 1 to 2B )
1st line
0 Lumpectomy or total mastectomy (+/- BR ) + sentinel node biopsy (SLNB) OR axillary node dissection (ALND)
ADJUNCT
- neoadjunct or adjunct chemo
- ( neoadjunct - treatment given surgery to shrink down tumour before surgery )
ADJUNCT -if mastectomy - whole breast
ADJUNCT -if lumpectomy - whole breast, and area around e.g all the way to above clavicle ,axilla etc.
HER +
- all of the above
+ ADJUNCT / NEOADJUNCT- trastuzumab =+/- pertuzumab (combined with adjuvant chemotherapy)
using dual anti- HER2 blockade can improve prognosis.
ADJUNCT - Trastuzumab emtansine - if residual invasive disease at time of surgery after neoadjuvant trastuzumab-based treatment
ADJUNCT - Neratinib - extended HER2 therapy - shown to reduce relaspe.
HORMONE RECEPTOR POSITIVE
ADJUNCT - endocrine therapy
pre menopasual
Tamoxifen or ovarian function supression ( drug or surgery (oophorectomy)used to stop ovary making oestrgen)
ADJUNCT
- bone health e.g Vitamin D , calcium , regular assessment of bone mineral density - cancer negatively impacts bone health - increased fracture risk.
THOSE ON AROMATASE INHIBITORS , OVARIAN FUNCTION SUPPRESSION SHOULD HAVE THIS - REDUCES DENSITY FURTHER
LOCALLY ADVANCED BC (STAGE 2B - 3) = only difference
1st line
Neoadjunct chemo
trastuzumab emtansine vs trastuzumab
Difference ?
Trastuzumab emtansine -
Combined drug
Trastuzumab -
monoclonal antibody - binds & blocks HER2 receptor on cancer cells.
emtansine - cancer drug
become active when it enters cancer cell and kills cell
What is metastatic BC
(MBC )?
MBC - Cancer spread beyond the breast and ipsilateral lymph nodes (axillary, internal mammary, infra- and supraclavicular)
DIAGNOSTIC FACTORS
0 Presence of risk factors
0 pleural effusion (if MNC confirmed - pleural fluid should be sent to cytology )
0 SOB - commonly secondary to pleural effusions
0 Bone pain (indicate possible spead to bone )
0 anorexia - common in terminal stage
0 Weight loss
- neurological pain , weakness , headaches , seizure - possible brain / peripheral NS metastases.
Investigations of metatastic BC ?
0 FBC - looking for bone / liver disease
0 LFTs
0 Calcium
- elevated may indicated bone disease
0 CXR - lung metastases
0 CT scan of chest and abdomen
0 Bone scan - if complain of bone pain , abnormal blood tests - FBC , LFT
investigations to consider
- MRI on area of concern
- biopsy to determine best course of treatment e.g is it hormone positive etc.
- multi gated acquisition (MUGA) scan - check baseline cardiac function if starting doxorubicin (chemo )or trastuzumab - reduce ejection fraction. if cardiac F not good enough might not be able to start therapy.
Treatment of MBC ?
- LINK
- too complcated to write out.
https://bestpractice.bmj.com/topics/en-gb/718/treatment-algorithm#patientGroup-0-0
visceral crisis - severe organ failure - significantly worse outcomes.
What is prostate cancer?
RISK FACTORS
TYPES
SYMPTOMS
Prostate adenocarcinoma ( cancer in the prostate gland)
Only affects male
RISK FACTORS
- aged over 50
- black
- Fx of PC
- Elevated PSA
TYPES
0 PC arises from luminal & columnar cells - most common
Less common
0 Transitional cell carcinoma - arises form transitional zone.
0 Small cell prostate carcinoma- arises from neuroendocrine cells
SYMPTOMS
early on - often asymptomatic- cancers usually occur in posterior peripheral zone , away from urethra so don’t cause problems with urination until the layer stage where they are bigger.
Later
- difficulty urinating
- pain on urination & ejaculation
- bleeding
Metastases
- commonly spreads to bone ( vertebrae pelvis )present as hip or back pain
What are the different zones of the prostate ?
0 Peripheral zone - contains 70 % of glandular tissue
0 Central zone - contains 25
% of glandular tissue + ejaculated ducts
0 Transitional zone - contains 5 % of glandular tissue + portions of prostatic urethra
- Contains transitional cells like in bladder
- this where benign prostatic hyperplasia occurs as transitional cells increase in number ,( can compress urethra) - in older men - common.
Prostate surrounded by capsule.
Diagnosis / investigation of suspected Prostate cancer ?
0 serum PSA
( can increase in other conditions e.g prostitis, benign prostatic hyperplasia)
0 Prostate biopsy
- transurethral ultrasound (TRUS) guided needle biopsy or MRI - TRUS guided
0 renal function- abnormal may indicate obstruction of ureters causing renal failure.
0 FBC
0
Digital rectal examination - if lump is in anterior portion would not be able to feel
Transrectal ultrasound or mri
Biopsy
Serum Prostate specific antigen ( PSA)
Treatment of prostate cancer ?
VERY LOW RISK
LOW RISK
if more than 10 years projected survival - observation first
if less - active surveillance.
1st line
0 Active surveillance
- monitoring with additionally prostate biopsies until symptoms become clinically evident.
0 Brachytherapy (B)- place radioactive material into the body next to required area. (Can be used as a Brachytherapy boost following EBRT.
0 External beam radiotherapy (EBRT)
0 Radical prostatectomy +/- lymph node dissection (RP + LND)
*(different options depends on patient preference e.g want to avoid side effects of treatment if they can )
SIMILAR FOR FAVORABLE INTERMEDIATE RISK
FOR UNFAVORABLE
- difference their is so active surveillance
HIGH RISK - NO FIXATION TO PELVIC MUSCULATURE OR SKETELON
0 RP + LND 0 EBRT + BB 0 EBRT + androgen deprivation therapy (ADT ) 0 EBRT + BB + ADT 2nd line 0 ADT alone
ATTACHED TO PELVIC M OR S
0 0 EBRT + BB + /- ADT
2nd line
0 ADT
METASTATIC DISEASE
0 ADT + / - Docetaxel (chemo ) or abiraterone ( suppress androgen synthesis ) - used in metastatic castrate sensitive PC - CAncer spread & can be controlled by lowering androgens e.g testosterone.
Examples of ADT
- bicalutamide
- flutamide
- Leuprorelin
- goserelin
- degarelix
- tamoxifen
PLUS DRUGS THAT PREVENT OSTEOPOROSIS
0 denosumab - monoclonal antibody
0 biphosphonate
0 Toremifene
ADJUNCT - systemic radiotherapy ADJUNCT - EBRT 2nd line Hormone therapy or chemo ADJUNCT denosumab OR biphosphonate OR Toremifene ( d, b, t)
3rd line
0Sipuleucel - immunotherapy - alternative first line for castration - resistant metastatic disease.
ADJUCNT-
( d, b, t)
Positive margins in the biopsy - cancerous found at the edge - indicates that some cancer cells are still in the body .
non metastatic - post RP with postive margins , not in lymph node
1ST line
0 radiotherapy
0 bbservation
non metastatic - positive lymph node
1ST line
0 ADT
0 Observation
https://bestpractice.bmj.com/topics/en-gb/254/treatment-algorithm#patientGroup-0-0
What is cervical cancer ?
cancer of the cervix
0 usually occurs after an infection of HPV.(human papilloma virus ) - in particular HPV 16 ETC.
TYPES
0 Squamous cell carcinoma
0 Adenocarcinoma - in epithelial cells of cervix.
RISK FACTORS
0 age 45 -49 0 HPV infection 0 Multiple sexual partners 0 immunosupression 0 early onset of sexual activity e.g under 18. 0 smoking
SIGNS & SYMPTOMS
0 abnormal vaginal bleeding
0 postcoital bleeding - after intercourse.
0 abnormal vaginal discharge e.g colour , smell
uncommon
0 obstructive uropathy 0 dyspareunia (painful intercourse ) 0 pelvic or back pain. 0 cervical mass 0 cervical bleeding on examination - speculum or vaginal exam.
if cancers spread past pelvic - can cause blood in urine , constipation.
Stages of cervical cancer ?
Grades - look at the cells
Stage 1 - confined to cervix only
Stage 2 - upper 2/3rd of vagina
Stage 3 - in the lower third of vagina / or extends to pelvic wall/ ureters
Stage 4a - Tumour invaded nearby pelvic organs e.f rectum , bladder , pelvic/ para -aortic lymph node
Stage 4b - spread to other parts of the body
https://www.youtube.com/watch?v=TzNtTAjp5Ok
more sub stages - watch the video for more.
GRADES
0 grade 1 (low grade) look most like normal cells
0 grade 2 look a bit like normal cells
0 grade 3 (high grade) look very abnormal and not like normal cells
How to diagnose suspected cervical cancer ?
at cervical screening - pap smear done - cells of the cervix collected and tested
0 Vaginal or speculum exam
(might show mass or bleeding )
0 colposcopy - procedure looks at the cervix & top vagina.
* (biopsy can be taken at the same time )
0 Biopsy
0 HPV test -indicated if pap cells show abnormality.
Treatment of cervical cancer ?
non pregnant , no longer want to get pregnant - early stage disease
0 radical Hysterectomy *( RH) + lymphadenectomy (L)
0 ADJUNCT - post -operative chemoradiation
cannot undergo surgery
0 chemoradiation
desires to get pregnant
radical trachelectomy (fertility sparing surgery) - remove cervix + upper third of vagina not uterus.
STAGE 1B2 – 2A
only difference:
chemoradiation can be used as first line
LOCALLY ADVANCED DISEASE
1st line
0 chemoradiation
METASTATIC DISEASE
0 combination chemo + Bevacizumab (VEGF - Angiogenesis inhibitors )
0 ADJUNCT - distant metastases that are able to locally treated e.g. surgical resection + / - EBRT
2nd line 0 single agent - chemo 0 bevacizumab 0 clinical trial 0 supportive care
3rd line
Pembrolizumab - immunotherapy
LOCAL OR REGIONAL RECURRENT DISEASE
0 Local treatment (e.g. EBRT) , surgical resection+ / - Chemo
PREGNANT
1st trimester
discuss termination - to allow treatment e.g. surgery , chemo
2nd , 3rd semester
chemo can be used - if wish to keep baby. - chemo may be delayed after birth.
baby should normally be delivered by C section.
For knowledge only
What would an abnormal PAP smear show ?
0 Atypical squamous cells (ASC)
- can either be ASC - US (US - unknown significance )
or ASC - H (h- with high grade epithelial lesions )- further testing recommended
0 Cervical intraepithelial lesions (CSIL )
can either be :
LSIL - low grade
HSIL - high grade
(cells are dysplastic )
What is endometrial cancer ?
cancer cells / tumor in glands of the endometrium
(lining of uterus )
endometrium - simple columnar epithelium
TYPES
Type 1 - most common -
o linked to excess Oestrogen
o slow growing o less likely to spread
ex-
Endometriod carcinoma / type of adenocarcinoma
NON ENDOMEREIOD CANCER
Type 2 -
subtypes
- Uterine serous carcinoma
- Clear cell carcinoma
o Not linked to excess Oestrogen
o faster growing
o more likely to spread.
RISK FACTORS
0 endometrial hyperplasia.
0 aged over 50.
- High levels of oestrogen
e.g - obesity - fat cells convert adrenal precursors into sex hormone.
- menopause
- HRT - hormone replacement
(associated with endometrial hyperplasia & cancer ) - tamoxifen use ( post- menopause use
indicated to be used for pre- menopausal use as a result) - blocks estrogen in breast but stimulates them in the uterus.
0 Fx of EC , Colorectal cancer , BR , Ovarian cancer etc.
- hereditary non -polyposis colorectal caner (Lynch Syndrome ) - increased risk of Endometrial , colorectal cancer.
0 PCS - polycystic S
0 radiotherapy for treatment of other cancer - rare but strong link.
Factors that reduce risk of endometrial cancer ?
0 hormonal contraceptives
0 older when you give birth
0 breastfeeding.
r ?
Stage 1 - carcinoma in uterus
Stage 2 - spread to cervix
Stage 3 - outer uterus but inside true/ lesser pelvis - cancer in vagina , pelvic lymph nodes
Stage 4 - beyond pelvis
Symptoms / signs of Endometrial cancer ?
0 Post menopausal bleeding / abnormal
uterine mass , adnexal mass
(adnexa - area near uterus containing ovary and Fallopian & associated vessels )
- found on (Bi -manual exam / pelvic examination - looks at female genital organs )
Investigations for suspected endometrial cancer ?
Pelvic (trans-vaginal ultrasound )
endometrial thickness > 5mm - suggest cancer + abnormal bleeding (post menopause - highly likely)
- can also detect polyps.
0 Outpatient Biopsy - histopathology
- identify tumour subtype , grade etc.
- Outpatient - don need to stay in hospital - recover at home.
0 Hysteroscopy , dilation & curettage
(Hysterectomy - telescope with camera & light passed into uterus to see inside womb.
- D & C - dilation of the uterus & surgically removing part of uterus lining
(this needs to be done if biopsy not possible or tolerated. )
0 can do a pap smear - although primarily for cervical cancer
0 FBC
- check for anaemia.
to consider
0 MRI of uterus , pelvis , abdomen - look at local extend of invasion of adjacent organs. r unnecessary investigations
- elevated.
0 Serum CA-125 - not really used may lead to over-treatment ,
0 LFTs
0 U & E
(looking for metastatic spread to liver , elevated ALT - bones of liver
CXR - lung metastases
Treatment of endometrial cancer ?
Stage 1 endometriod cancer ( no fertility preservation )
1st line
Low / low - intermediate risk
0 Surgery
ADJUNCT - post operative observation
Intermediate - high risk
0 Surgery
ADJUNCT - vaginal brachytherapy (VBT)
FERTILITY CONSERVING
1st line
Surgery
or careful counselling + progestin therapy e.g megastrol
Stage 1B - 2
sames as stage 1A - non fertility persevering
difference
High risk -
ADJUNCT - IS EBRT and/ or VBT =/ - chemo
STAGE 3-4 endometriod cancer / all non - entrometriod cancers
(TYPE 2 )
0 Staging surgery ( tissue removed and analysed ) + ADJUNCT chemo
Recurrent / incurable disease
- 1st line
0 Supportive care
ADJUNCT
- radiotherpay or/ and surgical resesction
ER - , PR - negative
ADJUCNT - pallative chemo
ER + , PR +
ADJUNCT hormone therapy or aromatase ingibitor.
Treatment of melanoma?
havent finished metastic section.
Non -metastatic (stage 0 - melanoma in situ )
1ST LINE - Surgical incision (0.5cm surgical margin - narrow)
2ND LINE - Non surgical , destructive or topical therapy e.g Imiquimod (TOPICAL ) (RADIOTHERAPY , CRYOTHERAPY , CURETTAGE , FULGURATION - DESTRUCTIVE TECHNIQUES).
(for poor surgical candidates , those who refuse surgery)
THIN MELANOMA (BRESLOW DEP < 1MM )
0 Surgical exision + (Sentinal node biopsy if palpable lymph nodes)
- IF BD - 1MM TO 4MM - SE + SNLB (sentinel node biospy - without palpable LN)
0 surgical margin :
1CM - BD (1MM TO 2MM)
2CM - BD (3MM TO 4MM) - IF BD > 4MM - SE + SNLB (without palpable )
lymph nodes)
(Surgical margins - 2-3 mm)
METASTIC - advanced to nodes
-surgical excision of regional lymph nodes
