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
